This document provides a summary of borderline personality disorder (BPD) through the case of a 28-year-old woman named Susan. Susan experienced childhood trauma and has struggled with unstable moods, relationships, and identity. The document then discusses the history and terminology of BPD, epidemiology, etiology related to trauma and family interactions, common features and symptoms organized into four categories, differential diagnosis, DSM-IV diagnostic criteria, course, prognosis, and treatment options including psychotherapy approaches like dialectical behavior therapy.

1. BORDER LINE PERSONALITY
BY
EMADULLAH SHAFI
RAK MEDICAL AND HEALTH SCIENCES
UNIVERSITY, UAE

2. A CASE OF BPD
Susan, 28 yrs old female, She experienced a troubled childhood,
including her father dying when she was 4 and her mother marrying
a man who sexually abused Susan
She went to school, did well. Once out of school she ran into many
problems. Colleagues and employers did not like her moodiness,
she was inappropriately seductive at times
Her greatest difficulty occurred in her relationships. Fairly
attractive, she never had any trouble attracting men. However, her
relationships became stormy and self destructive

3. She would rapidly get very angry when her BF wasn’t available to
her. When her most recent boyfriend went to visit his parents she
became so angry that she found a man at a bar and spent the
weekend with him.
The first night she met a man, she would idealize him, share every
bit of her history. And after somedays she would hate him
At times this woman would feel she did not exist and would cut her
arms in dissociative episodes. She could never tolerate being
alone, she would feel bored, empty and desperately throw herself
into some risky activity
Since finishing college she has chosen various paths. Went to law
school, dropped out. Worked for a magazine and she quit.
Sometimes she feels rage at her mother for not protecting her and
at times she idealizes her

4. WHY THE TERM “BORDERLINE”
• Adolf stern in 1938 used the term “borderline”. It described a
group of patients who were on a borderline between neurosis
and psychosis. He thought this as a mild form of schizophrenia
• Current trend is to call it “Emotional Intensity Disorder”
• Better accepted by patients – more meaningful

5. EPIDEMIOLOGY
• 1 to 2 percent in General population
• Three times more often in women then men
• A study done on 35,000 subjects in 2008 stated lifetime risk of
BPD as 5.9%
• 20 % of the inpatients and 10 % of the outpatients in Psychiatry

6. ETIOLOGY
• Reduced serotenergic activity in 5-HT system inhibits ability to
modulate or control impulsive and aggressive behavior
• Differences b/w BPD and non BPD patients in serotenergic functioning
• Repeated exposure to stress may blunt serotenergic activity (frequent
increases in cortisol)
• Stress  frequent increases in cortisol  blunting of serotenergic
activity  emotion dysregulation

7. TRAUMA
• Childhood Sexual Abuse (CSA)
• Historically considered a significant risk factor for BPD
• 75% of patients with BPD have a hx of CSA

8. FAMILY INTERACTIONS
• Neglect
• Emotional uninvolvement

9. CO MORBIDITY
• These patients are at increased risk for
 major depression,
 substance abuse or dependence,
 eating disorder (notably bulimia),
 posttraumatic stress disorder (PTSD)
• Borderline personality disorder cooccurs with most other
personality disorders.

10. FEATURES OF BPD
• Splitting – Patient divides people into two categories, those who
hate him and those who like him. These feelings are changeable
• Projective identification – the patient attributes a positive or
negative attitude towards a person and seeks to engage this
person in various interactions that will confirm a person’s belief
• Patient has intense aggressive need
• Patient has a marked fear of abandonment
• Turning against self is prominent
• Identity disturbance

11. FOUR CATEGORIES FOR BORDERLINE SYMPTOMS
• Poorly regulated emotions
• Mood swings and unstable emotions
• Anxiety
• Inappropriately intense anger
• Difficulty controlling anger
• Chronic feelings of emptiness
• Impulsivity
• Reckless behavior
• Suicidal behavior and self harm
• Munchausen’s Syndrome and by Proxy
• Suicide

12. • Impaired perception or reasoning
• Paranoid thinking
• Dissociative episodes
• Depersonalization
• Unstable self image or sense of self
• Markedly disturbed relationships
• Intense and unstable interpersonal relationships
• Black and white thinking
• Frantic efforts to avoid real or imagined abandonment

13. CAN LOOK LIKE…..
• Schizophrenia
• hallucinations, illusions, paranoia
• Bipolar Affective Disorder
• mood lability and anger
• Major Depressive Disorder
• suicidal, depressed
• Antisocial Personality Disorder
• legal problems

14. DIFFERENTIALS OF BPD
• Psychotic disorder – impaired reality testing persists
• Mood disorder – the mood disturbance is non reactive. Can be
difficult to differentiate from Major depressive disorder with
atypical features
• Personality change secondary to a GMC – results of medical
tests are positive
• Schizotypal personality disorder – affective features are less
severe

15. DIFFERENTIALS OF BPD CONTD.
• Antisocial personality disorder – attachment ability is more
severe
• Histrionic personality disorder – suicide and self-mutilation is
less common. Also these patients tend to have more stable
interpersonal relationships

16. DSM-IV DIAGNOSTIC CRITERIA
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, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal
or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending,
sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or
self-mutilating behavior covered in Criterion 5.

17. 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating
behavior
6. Affective instability due to a marked reactivity of mood (e.g.,
intense episodic dysphoria, irritability, or anxiety usually lasting a few
hours and only rarely more than a few days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (e.g.,
frequent displays of temper, constant anger, recurrent physical fights)
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms

18. MANAGEMENT OF
BPD

19. PHARMACOTHERAPY
• In controlling anger, psychotic episodes – Anti psychotics
• For depressed mood and anxiety– Antidepressants particularly
Alprazolam(Xanax) but some patients show disinhibition with
these drugs
• MAOI – in modulating impulsive behavior
• To improve global functioning – Carbamazepine(tegritol)
• Fluoxetine have proved to be useful

20. PSYCHOTHERAPY – TREATMENT OF CHOICE
• Difficult for the therapist and the patient
• More difficult for the therapist
 Patient’s impulsive behavior
 Projective identification
• Social skills training is very important in improving the patient’s
interpersonal relationships

21. COGNITIVE BEHAVIORAL THERAPY
• Cognitive therapy refers to an approach that focuses on a
person’s cognitions i.e their thoughts, assumptions, and beliefs.
• The patient learns to recognize and change faulty or
maladaptive thought patterns
• Behavioral therapy focus on changing a person’s unhealthy and
problematic behaviors, actions, and responses
• Focus is not on “WHY” something happens, but changing the
process to prevent, alter, or replace it with a healthier more
effective behavior

22. DIALECTICAL-BEHAVIORAL THERAPY
• Targets suicidal and parasuicidal behaviors and thoughts
• Focused on improving motivation for skillful behavior through
management of issues and problems as they come up in day to
day life
• Recent studies have shown subjects receiving DBT were half as
likely to make a suicide attempt, required fewer hospitalizations
for suicide ideation, and had lower medical risk across all
suicide attempts and self-injurious acts combined.

23. • Transference-focused Psychotherapy - aims to correct
distortions in the patient's perception of others
• Mentalization therapy - focuses the ability to perceive the mind
of others as distinct from one's own and hence to reconsider
and reassess one's own perceptions of reality
• Schema therapy - the newest of the psychotherapies for BPD.
Schema therapy integrates elements of cognitive
therapy, behavior therapy, into one unified, systematic approach
to treatment.

24. COURSE AND PROGNOSIS
• Course is variable. Most commonly follows a pattern of chronic
instability in early adulthood, with episodes of serious affective and
impulsive dyscontrol.
• The impairment and the risk of suicide are the greatest at the young
adult years and gradually wane with advancing age.
• In the fourth and fifth decades of life, these individuals tend to attain
greater stability in their relationships and functioning
• A study published 2010 on hundreds of patients and followed for
several years. Half recovered, meaning they no longer met the criteria
of BPD, and half of the patients had reduction in symptoms

25. THANK
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