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Borderline personality disorder is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Borderline personality disorder occurs in 2 to 3 percent.

Borderline personality disorder is approximately five times more common among first-degree relatives of those with the disorder than in the general population. There is also an increased familial risk for substance abuse, antisocial personality disorder.


Family-pedigree studies have suggested that patients with borderline personality disorder may be nonspecifically predisposed toward poor regulation of both impulses and moods; other preliminary evidence shows that the dysregulation may be related to the limbic system's low threshold for excitability. Other work indicates that deficiencies in central serotonin function may be linked.

Studies have suggested that patients with borderline personality disorder have a high frequency of early parental loss or traumatic separations or both. Their intense attachment needs have been stimulated and frustrated in ways that often lead to a search for maternal substitutes. Perhaps as a consequence, such patients (compared with patients with antisocial personality disorder) more frequently have histories of an extended use of transitional objects in childhood, which sometimes persists.

The patients' hostile and conflictual relationships with their mothers are generally not counterbalanced by positive relationships with their fathers, and both parents usually have significant psychopathology. Mothers tend to be erratic and depressed, whereas fathers are often absent or characterologically disturbed. The families are also frequently flawed by disruptive behavior.

Overall, the available evidence best supports the disorder's multifactorial origins. It appears to be a final common pathway.

Diagnosis and clinical features

Patients with borderline personality disorder are severely dysfunctional. Their clinical presentation is intimately connected to the interpersonal context in which they are observed; most of the disorder's observable features are highly sensitive to interpersonal stress. For example, within the context of a supportive relationship (or within a structured holding environment), appealing, waiflike, dysthymic features are evident. Yet the perception of the impending loss of such a relationship.

The relationships of persons with borderline personality disorder tend to be unstable, intense, and stormy. Contributing to that instability and storminess are sudden and dramatic shifts in their views of others; the views may alternate between extremes of idealization and devaluation or of seeing others as beneficent supports and then as cruelly punitive.

Stressful experiences--often the absence of a relationship or an external structure--can result in a variety of problems.

Course and prognosis

Before adolescence, such psychological handicaps as concentration problems, learning disabilities, and social alienation are often present. Those problems gradually evolve into the classic symptoms of the disorder during adolescence and early adulthood. The course of borderline personality disorder is variable but is often characterized by severe dyscontrol of mood and impulses and by the high consumption of health care resources, especially during the 20s. In their 30s and 40s a significant number of patients (40 to 60 percent) appear to attain some stability in their relationships and vocational functioning.


Long-term individual psychotherapy can be helpful to patients with borderline personality disorder, but most psychotherapies are discontinued angrily and impulsively. The intense affects, demands for care, and repetitious crises that permeate the early stage of treatment evoke intense feelings of helplessness and anger among

Successful therapies are characterized by progressively diminished acting out, a period of overt dependence, and the direct expression of hostile feelings. Such processes usually take five years or more.

Short-term psychotherapy can be useful to manage crises or to introduce long-term forms of therapy. Psychoanalysis is usually contraindicated because patients easily regress in response to its lack of structure. Patients reportedly successfully treated with psychoanalysis rarely meet the criteria.

Pharmacological treatments. Several controlled studies indicate that low doses of antipsychotics may help alleviate sustained symptoms of obsessive ruminations, somatic complaints, ideas of reference, and dissociative experiences. Some patients benefit from monoamine oxidase inhibitors (MAOIs), but the risk of noncompliance makes them hazardous. The serotonin-specific reuptake inhibitors (SSRIs) have been shown to diminish both impulsive and mood symptoms, and because of their safety they are usually the first class of drugs that are tried. Carbamazepine (Tegretol) has been reported to decrease impulsive, self-destructive behaviors. Clinical experience suggests that lithium (Eskalith) may sometimes diminish affective instability or impulsivity, but its use for patients with borderline personality disorder has received little empirical support. Hostile, impulsive, and self-mutilative behaviors may be aggravated by benzodiazepines or, in some cases, tricyclic antidepressants.