Textbook of child and adolescent mental health
Chapter 4
Borderline personality disorder

Introduction

Borderline personality disorder is characterized by a pervasive and persistent pattern of instability and impulsivity.

Epidemiology

Prevalence

Prevalence of borderline personality disorder is estimated to be between 0.7 and 1.8%.

Gender and culture

Prevalence in the general population is considered to be similar for both gender. In clinical samples, females represent three quarters of all patients.

Thresholds for each criteria in the DSM may differ depending on their and their patient’s culture.

Burden of illness

The consequences of borderline personality disorder for the people around the sufferer depend on their vulnerability to the behaviour and demands of borderline personality disorder patients.

Patients with borderline personality disorder are exposed to risks due to impulsivity. Instability in emotional and inter-personal relationships leads to communication problems.

Age of onset and course

A diagnosis should not be made before the age of 18 years. Diagnosis is made earlier when symptoms are clear and persistent.

Remission is common. Remission is in most cases a reduction of the number of symptoms below the diagnostic threshold. There appear to be two clusters of symptoms: 1) stable and persistent, anger, feelings of abandonment 2) unstable or less persistent, self-harm and suicide attempts.

The risk of dead by suicide is between 4 and 10%.

Causes and risk factors

The cause of borderline personality disorder is unknown.

Repeated childhood trauma is a frequent element in borderline personality disorder.

Early maternal separation is associated with both borderline personality disorder and the persistence of borderline personality disorder symptoms over time.

Inheritance of borderline personality disorder is polygenic.

Diagnosis

Subtypes

Subtypes of borderline personality disorder may be defined by the comorbidities.

Some researchers propose two subtypes: 1) dependent, characterized by ambivalent, unstable relationships 2) impulsive, characterized by impulsive acts in multiple areas.

Presenting symptoms

Presentations are often prompted by another psychiatric problem, problematic behaviour, or relationship problems.

From a categorical to a dimensional concept of borderline personality disorder

For a dimensional diagnosis of borderline personality disorder, the following would be required: 1) significant impairments in self and interpersonal functioning 2) one or more pathological personality traits domains or trait facets 3) relatively stable across time situations 4) symptoms are not better understood as normative for the individual’s developmental stage or socio-cultural environment 5) symptoms are not due to substance use or a general medical condition.

Within this framework, personality disorders would lie at the extreme end of personality traits.

Comorbidity

Borderline personality disorder is very often comorbid with: depression, anorexia, bulimia, substance abuse, ADHD, antisocial personality disorder and avoidant personality disorder.

Treatment

Aims

Setting a treatment plan and treatment goals is the first step in management, which will be influenced by the patient’s instability.

Care framework

Treatment of adolescents with borderline personality disorders should usually be delivered as outpatient. Determining the care framework involves: risk evaluation, mental state, level of psychosocial functioning, aims and motivation of the patient, social environment, comorbidity and predominant symptoms.

Inpatient treatment can be considered for cases with severe comorbidity and when crisis management or day hospitalisation are unable to contain the patient.

Biological treatments

Drug treatment should not be used specifically for borderline personality disorder. Comorbid disorders may require medication treatment.

Psychotherapy

Psychotherapies used to treat borderline personality disorder share many aspects.

When considering psychological treatment for a person with borderline personality disorder, clinicians should take into account: patient’s choice and preference, degree of impairment and severity, patients’ willingness to engage with therapy and their motivation to change, patients’ ability to remain within the boundaries of a therapeutic relationship and the availability of personal and professional support.

Dialectical behaviour therapy

Involves an integrative approach grounded on a bio-psycho-social understanding of the disorder. Emotional regulation is considered the main problem.

Schema focused therapy

Places emphasis on the therapeutic relationship, affect and mood states, lifelong coping styles, entrenched core themes, and more discussion of childhood experiences and developmental processes.

Mentalization based treatment

Mentaliziaton is the ability to differentiate and separate out one’s own thoughts and feelings from those of other people. The aspects of mentalization are emphasized, reinforced and practiced.

Transference focused psychotherapy

This assumes that there is a psychological structure that underlies the specific symptoms of borderline personality disorder. In such an organisation, thoughts and feelings about self and others are split into dichotomous experiences. Either/or states determine the nature of the patient’s perceptions. Treatment focuses on transference because it is believed that patients live out their predominant object relations dyads in the transference.