A systematic literature review of the etiology of borderline personality disorder from an ecological systems PERSPECTIVE

Borderline Personality Disorder (BPD) is one of the most common, complex, costly, and severely impairing personality disorders, affecting an estimated 2% to 9% of the general population and 40% to 44% of the inpatient psychiatric population. A review of the literature was conducted using a systematic methodology. By incorporating an ecological systems perspective, a holistic and comprehensive critique of the literature surrounding the etiology of BPD is presented. The findings reveal that the etiology of BPD is a complex integration of psychological, biological, and social factors. More specifically, however, this review found that: (1) the etiology of BPD is complex and has many factors, (2) the dominant discourse about the etiology of BPD is based primarily in the psychological and biological literature, and (3) the examination of BPD etiology has focused solely on the individual and microsystems levels, neglecting to consider systemic factors such as the impact of discriminatory health and mental healthcare practices. Findings and future directions are explored through the ecological systems theory lens.     

Racial Differences Between African and White Americans in the Presentation of Borderline Personality Disorder

Borderline personality disorder (BPD) is commonly thought of as a disorder of White females. Despite evidence indicating similar prevalence rates across races and genders, no study has examined the experience of BPD among ethnic minorities and how this differs from Whites. The affective and behavioral symptoms of BPD were studied in 17 African Americans and 27 White Americans with the disorder. Results indicated that African Americans experience greater affective intensity and emotional dysregulation, fewer self-harming behaviors, and more thoughts of interpersonal aggression than Whites. Differences in affective symptoms were accounted for by group differences in substance use and receipt of inpatient services, whereas differences in behavioral symptomatology persisted after adjusting for potential confounders. These findings suggest that not only is BPD not a disorder exclusive to White females, but that the experience of the disorder may differ substantially across races. Implications for future research and directions for developing culturally relevant treatments are discussed.     

Confronting Myths and Stereotypes About Borderline Personality Disorder

SUMMARY

The clinician treating a patient with borderline personality disorder (BPD) is often faced with complicated challenges, from making and communicating an accurate diagnosis, to implementing an appropriate, informed plan for treatment. Myths and stereotypes about BPD, and the individuals who may carry the diagnosis, likely complicate effective recognition and treatment of the disorder. BPD has been a controversial diagnosis among clinicians since its inception, and it is poorly understood among the general public. Pressures to avoid an explicit exploration of the diagnosis stemming from myths and stereotypes about the disorder can come from a number of sources, including other clinicians, family members and patients themselves. The results of minimizing or ignoring the contribution of borderline pathology may be detrimental. Clinical decisions based on outmoded thinking about diagnosis, prognosis, treatment efficacy, and availability of resources may deny patients optimal care. Integrating current findings into consideration of a BPD diagnosis and design of appropriate treatment, free of misconceptions about the condition, may help limit the untoward effects associated with failure to appreciate elements of borderline personality.     

Borderline Personality Disorder

SUMMARY

Our knowledge about borderline personality disorder (BPD) has taken some unexpected turns: BPD is less stable, it is more genetic, and it is more treatable than we would ever have imagined even 15 years ago. These developments have profound implications for understanding and treatment of individuals with BPD.     

Borderline Personality Disorder and Hospitalization

SUMMARY

This chapter reviews and discusses the issues and controversies related to the hospitalization of suicidal patients with a diagnosis of borderline personality disorder. It highlights the challenges faced by both the clinical staff and a prototypical patient during a hospitalization. Included are a discussion of the transference and counter-transference that arise during inpatient treatment, the stressors on the staff as well as on the patients themselves. The chapter offers suggestions for enhanced in-hospital treatment, including increased collaborative decision-making, clear and realistic short- and long-term goals for patient and family, and increased supervision and ongoing education of staff.     

Borderline Personality Disorder Across the Life Span

SUMMARY

Borderline personality disorder is characterized by affective dysregulation, intense, unstable interpersonal relationships, impulsivity and unstable identity. It overlaps considerably with both PTSD and bipolar spectrum disorders. Research on true late-life BPD is limited, but suggests that some of the core features of BPD including interpersonal difficulties, unstable affect and anger remain relatively unchanged, while impulsivity and identity disturbance decline or change their mode of expression in late life. Diagnosis of BPD in late life requires flexible application of the standard diagnostic criteria as well as a thorough longitudinal history. The etiology of BPD is best explained as a combination of genetic, neurobiological vulnerability combined with childhood trauma, abuse or neglect that leads to dysregulated emotions, distorted cognitions, social skills deficits, and few adaptive coping strategies. Treatment options include pharmacotherapy (especially mood stabilizers, SSRIs and atypical antipsychotics) and psychotherapeutic interventions that focus on distress tolerance, affective regulation, changing distorted beliefs, and introducing new social and relationship problem-solving skills (especially Dialectical Behavior Therapy and Schema Focused Cognitive Therapy). In late-life care environments, such as nursing homes and other residential facilities, staff need to be empowered to set appropriate limits on problematic behavior while maintaining empathy and validating the painful affect patients often experience.     

EMDR用于边缘型人格障碍的治疗

边缘型人格障碍(BPD)患者通常有显著的功能行使能力损害。其特征是冲动、情绪不稳、人际困难和身份认同问题,常常导致自杀行为和自杀姿态。虽然传统上认为BPD是一种慢性持久的障碍,但近期的研究却提示它可能会随着时间流逝而有所缓解,而且心理治疗可以促进缓解。BPD的病因与童年期虐待和不恰当的依恋关系有关。由于童年期虐待和创伤的重要意义,被公认有效的创伤治疗方法——眼动脱敏与再加工(EMDR)可能作为BPD的合理备选治疗方案之一。本文中的个案所获得的良好疗效阐明了EMDR在BPD治疗中的运用,提示有理由进行深入的对照研究。     

Supportive Psychotherapy for Borderline Patients

SUMMARY

An imagined conversation between a clinician/teacher and a beginning therapist conveys the concept of a psychoanalytically informed supportive psychotherapy for borderline patients and incorporates the major hypotheses as to the origin of the disorder. Within a basically developmental point of view, the treatment recognizes the contributions of genetics, animal studies, neuroscience, early interpersonal relationships and the object relations that derive from them. The psychodynamics of a typical case are considered from all of these viewpoints, while the student-therapist is encouraged to keep in mind the basic concepts of psychoanalysis. These include: unconscious mental activity, transference, and the internalization of the therapist's attitude of respectful listening, which leads to the capacity to listen in that way to oneself and others.