Psychiatric Annals

CME Article 

Borderline Personality Disorder: Impact, Overlap, and Comorbidities

Syed Z. Iqbal, MD; Lindsay Nicole French-Rosas, MD; Sophia Banu, MD; Jin Yong Han, MD; Asim A. Shah, MD

Abstract

Borderline personality disorder (BPD) is associated with functional impairment, characterized by marked impulsivity, instability of mood, interpersonal relationship problems, and suicidal behaviors with high suicide rates. It affects interpersonal relationships in all domains including child rearing, which can be a challenge for parents with BPD. BPD may also lead to poor socioeconomic outcomes due to frequent job losses and lack of productivity; criminal behavior from impulsivity; and increased resource use, resulting in high health care treatment costs. BPD is comorbid with other mental health disorders; therefore, its identification and treatment are paramount for management. The clinical challenge centers on managing chronic suicidality. Treatment consists of various modalities, including psychotherapy and psychopharmacology. [Psychiatr Ann. 2020;50(1):14–18.]

Abstract

Borderline personality disorder (BPD) is associated with functional impairment, characterized by marked impulsivity, instability of mood, interpersonal relationship problems, and suicidal behaviors with high suicide rates. It affects interpersonal relationships in all domains including child rearing, which can be a challenge for parents with BPD. BPD may also lead to poor socioeconomic outcomes due to frequent job losses and lack of productivity; criminal behavior from impulsivity; and increased resource use, resulting in high health care treatment costs. BPD is comorbid with other mental health disorders; therefore, its identification and treatment are paramount for management. The clinical challenge centers on managing chronic suicidality. Treatment consists of various modalities, including psychotherapy and psychopharmacology. [Psychiatr Ann. 2020;50(1):14–18.]

The term “borderline personality” was proposed by Adolph Stern in 1938 who described a group of patients that neither fit into the psychotic nor psychoneurotic group. In 1975, Otto Kernberg introduced the term “borderline personality organization,” which refers to a persistent pattern of behavior that is characterized by instability that reflects disturbed psychological self-organization.1 It has a characteristic pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image (Table 1).2–4 It is often diagnostically comorbid with other mental health disorders.1 The course of this disorder is variable as most people show symptoms in late adolescence or early in adult life, although some may not come to attention until much later.1 It is associated with significant impairment, especially with sustaining stable relationships, and recurrent self-harm, which leads to physical impairment and disability.1

Descriptive Diagnostic Criteria of Borderline Personality Narrated from DSM-5a

Table 1.

Descriptive Diagnostic Criteria of Borderline Personality Narrated from DSM-5

Epidemiology

Borderline personality disorder (BPD) is an internationally recognized personality disorder that continues to receive a lot of attention due to its varied presentation and difficulty in treatment. There has been little epidemiological research about the disorder outside of the Western hemisphere.1 The point prevalence of BPD is 1.6%, and the lifetime prevalence in one survey was found to be 5.9%.4,5 Its prevalence is 6% in primary care settings, 10% among people seen in outpatient mental health clinics, and about 20% among psychiatric inpatients.4,6 In clinical settings, it is more common in women (75%).4 This difference is attributed to the fact that more women seek treatment as compared to men.5 However, according to an epidemiological survey, the lifetime prevalence between men and women was about the same in the community settings.3,5 The prevalence of BPD may decrease in older age groups.4 In community-based samples of children and adolescents, the prevalence is 11% at age 9 to 19 years and 7.8% at age 11 to 21 years.2 It is characterized by a high mortality rate due to suicide, with 60% to 70% attempting suicide, and 10% completing suicide.1,2,7

Impact of Borderline Personality Disorder

BPD is characterized by difficulty in interpersonal functioning, which is comprised of disagreements, ambivalence, anger, sadness, and emptiness.8 Marital relationships are affected as couples show lower marital satisfaction, higher attachment insecurity, and communication problems.9 They also show higher levels of violence with an increased risk for domestic violence either as perpetrator or victim.9 BPD is the fourth leading cause of disability in women and the sixth leading cause among men age 15 to 34 years.10 Impulsive behaviors, which include substance abuse, reckless driving, and promiscuous behaviors, lead to failure to meet social roles and obligations. It also results in poor academic and occupational achievement.10 Occupational dysfunction is related to low education levels, conflicts in the workplace, dismissal or demotion, and unemployment.11

Parents diagnosed with this disorder find the emotional aspect of parenting challenging and stressful.12 They are sometimes unable to establish a secure attachment with their children.12 They have difficulty in interpreting their infants affect, and often provide inconsistent responses to their needs. The children who are effected are noted to be withdrawn from social activities, resulting in the development of avoidant patterns in interpersonal relationships in the long term.12 “The environment in the family is often hostile with a low level of bonding and attachment.13 Children also exhibit dysfunctional attitudes with poor interpersonal relationships.13 Early intervention should be provided to parents to promote sensitivity and perception of competence in parenting skills.13

BPD requires high use of treatment services, resulting in high direct and indirect health care costs.14 Direct costs include all treatment costs related to hospital days and emergency department visits. Indirect costs include production losses and sickness benefit payments due to absent days.14 There are a few studies estimating the cost of this illness. Studies performed in German and Dutch populations reported annual costs for medical care of more than $18,000 per patient (purchasing power parity) direct cost versus $23,000 per patient (purchasing power parity) in medical care and productivity loss.15 A study conducted in the United Kingdom compared the costs of care in patients with personality disorders in contact with primary care services. It was estimated that patients with personality disorders incurred a cost of approximately $3,945 per person annually, including health care costs and productivity losses. In contrast, only $2,104 per person annually was lost in patients who did not have comorbid personality disorder.1

Patients with BPD engage in risky behaviors, often leading to criminal justice system involvement.16 It is found that up to 30% of prisoners meet full diagnostic criteria, whereas 93% meet at least one criterion for diagnosis.16 This is related to the long-standing impulsivity, affective instability resulting in rage reactions and violent crimes, comorbid antisocial personality features, and perpetrating domestic violence.17 Prisoners with BPD have higher psychiatric comorbidity with poor quality of life and overall worse functioning when compared to prisoners without BPD.16 They also have a higher risk of disruptive behaviors and institutional misconduct, such as arguments with staff and the manifestation of psychological aggression. Intervention that addresses the behavioral dysregulation may not only improve prison adjustment but may also reduce the time and resources spent by the correctional staff to manage these prisoners.16

BPD also impacts neuropsychological functioning that affects sustaining attention, processing speed, recovery processes of immediate and deferred memory, and executive function of the prefrontal lobe.18 The most significant deficit is found in the subdomain of planning.19 Cognitive rehabilitation could be useful in the treatment of this disease. It can provide results that can be extrapolated to the daily functioning of the patients, improving many problems these patients encounter in their daily life.18

Overlap and Comorbidities with Borderline Personality Disorder

Patients with BPD have consistently high rates of mood, anxiety, posttraumatic stress disorder (PTSD), substance use, and eating disorders.20 Bipolar disorder and BPD frequently co-occur with numbers ranging between 8% and 18%.21 Distinguishing features include more relationship instability and interpersonal and trust issues with fear of abandonment. It has a negative impact on the course of bipolar disorder with increased rates of hospitalization, longer treatment duration, and worse treatment response.21 Quality of life and outcomes in bipolar disorder are negatively affected; therefore, appropriate assessment and treatment of comorbid borderline personality disorder is crucial.22

The lifetime prevalence of major depressive disorder (MDD) in BPD ranges from 37% to as high as 87%.20,23 Depressive symptoms that appear as part of BPD are often related to a clear stressor and are transient.23 They are a maladaptive means of expressing hopelessness, disappointment, and anger. The transient depressive symptoms of BPD are often indistinguishable from those of MDD. However, the quality of the depression in BPD is different, characterized by more unstable negative affect, a deep sense of worthlessness, feelings of loneliness and emptiness with rare melancholic symptoms, and increased suicidal thoughts and behaviors.23

BPD has a high risk of comorbid anxiety disorders, up to 60%.20 It negatively affects the course of some anxiety disorders, specifically generalized anxiety disorder (GAD) and social phobia.23 Neither GAD nor social phobia predicts the course of BPD. Both arise as expressions of BPD traits, as perceived social threats that may trigger anxiety and fearfulness in BPD.24 A worsening course of BPD predicts social phobia relapse, illustrating that the classic BPD fear of separation and abandonment increases the likelihood of expressing social fears.24 Panic disorder does not have a significant longitudinal relationship with BPD, which shows that it can be better accounted for by other diagnoses, such as substance use disorders and PTSD.24

Up to 40% of those with BPD have comorbid PTSD, although some estimates are as high as 57%.20,25 Neurological changes of reduced amygdala and hippocampus volume are observed in both BPD and PTSD.25 Patients with BPD have significantly increased rates of childhood abuse and are twice as likely to develop PTSD.25 Comorbidity could be the result of increased trauma exposure as there is a higher risk for victimization or other traumas later in life, possibly due to impulsivity and chaotic relationships, which increase the risk for PTSD. High rates of PTSD in BPD may show greater vulnerability to the psychological effects of trauma with lower adaptability to recover from traumatic events.25

BPD has a correlation to substance use disorders with rates as high as 38%.26 It shows higher rates of lifetime drug use, specifically of cannabis, stimulant, cocaine, hallucinogenic, opioid, and sedative use.26 Substance use can contribute to several BPD diagnostic criteria, such as affective instability, interpersonal problems, impulsivity, and dissociation.26 Comorbidity can also be due to criteria overlap between substance use and BPD with shared features, such as impulsivity.26 Research shows an increased rate of use of alcohol, opiate, and cocaine use in those with BPD, hypothesized to be because of the effect on stimulating the endogenous opiate system, as BPD exhibits dysregulation of this system.26 Substance use in patients with BPD is directly linked to patient outcomes and the presence of one disorder can complicate the treatment of the other.26

Lifetime prevalence rates of eating disorders range from 3% to 26% in those with BPD.20 The style of personality psychopathology is related to the type of eating disorder pathology.27 For example, anorexia nervosa (eg, restricting type) with traits of control and restraint is often seen in personality types characterized by detail, order, and perfectionism. Anorexia nervosa (eg, binge-eating/purging type) is characterized by higher levels of impulsivity, seen in the binge-eating and purging behaviors.27 One study found that BPD was the most common personality disorder associated with this subtype of anorexia due to impulse control issues with a prevalence rate of 25%.27

Similarly, bulimia nervosa, with its higher level of impulsivity, is associated strongly with BPD with a comorbid rate of 28%.27 Given that impulse control issues in BPD are linked to impulsive eating disorders, it is not surprising that rates of binge-eating disorders and obesity are also higher among those with BPD, with prevalence rates ranging from 6% to 30%.27 BPD is present in a significant group of people who are obese and is a factor in maintaining obesity.27

The association between nonsuicidal self-injury (NSSI) and BPD is especially significant as most BPD patients engage in NSSI (ie, 49%–90%).28 NSSI refers to deliberate destruction of body tissue without lethal intention, including self-cutting, burning, or beating behaviors.28 BPD patients with a history of self-mutilation have twice the rate of suicide than those without it, as they experience intense feelings of depression, hopelessness, aggressive behaviors, and affect instability.29 They often underestimate the lethality of their suicidal behaviors and have prolonged and persistent suicidal thoughts.29

Conclusion

The treatment of patients with BPD is challenging. Untreated BPD can have a significant impact on interpersonal relationships, which not only affects family functioning but also decreases productivity in terms of frequent job loss. BPD can be comorbid with a variety of mental health disorders; however, identification and prompt treatment can improve prognosis.

References

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Descriptive Diagnostic Criteria of Borderline Personality Narrated from DSM-5a

<list-item>

Fear of abandonment

</list-item><list-item>

Unstable relationships alternating between idealization and devaluation

</list-item><list-item>

Disturbance in identify with poor sense of self

</list-item><list-item>

Impulsive behaviors, including unsafe sexual practices, excessive spending, and substance use

</list-item><list-item>

Suicidal and self-injurious behaviors

</list-item><list-item>

Reactive mood due to transient episodes of dysphoria, irritability, and anxiety

</list-item><list-item>

Persistent feelings of emptiness

</list-item><list-item>

Anger issues due to difficulty in controlling anger/aggression

</list-item><list-item>

Stress-related paranoia or dissociative symptoms for a limited period of time

</list-item>
Authors

Syed Z. Iqbal, MD, is an Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Lindsay Nicole French-Rosas, MD, is an Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Sophia Banu, MD, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Jin Yong Han, MD, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Asim A. Shah, MD, is a Professor and the Executive Vice Chair, Menninger Department of Psychiatry and Behavioral Sciences; and a Professor, Department of Community and Family Medicine, Baylor College of Medicine.

Address correspondence to Syed Z. Iqbal, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, One Baylor Plaza, BCM350, Houston, TX 77030; email: Syed.Iqbal@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20191206-01

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