Essay: Borderline Personality Disorder

Due to the heterogeneous condition of BPD, the disorder most commonly co-occurs with mood disorders with a prevalence of 70 to 90% (Zanarini et al., 1989;). The weight of evidence suggests that there are core atiological features that point to BPD being a distinct disorder (Zanarini et al., 2005). BPD, as with all Cluster B personality disorders, has many symptoms that make up Axis I conditions, and are consistent with an ‘externalizing’ way of coping (Paris, 2003). However, Cluster A personality disorders use cognitive symptoms and Cluster C use internalizing symptoms (Paris, 2003).
Elaborating on Borderline Personality Disorder Symptoms
People with BPD are very sensitive to the way others treat them, and are known to exhibit a phenomenon, sometimes called splitting or black-and-white thinking, which includes a positive shift from idealizing others (intense love and affection), to negative, devaluing them (feeling anger or hate) in response to perceived kindness or threats (Linehan, 2006). They feel emotions more easily, more intensely, deeper and for longer than others, which makes them especially prone to dysphoria, or feelings of mental and emotional distress (Linehan, 2006). They have difficulty knowing their goals, as well as who they are, what they value and prefer, which causes them to feel ’empty’ or lost. Zanarini et al. (2005) describe how people with borderline are often aware of the intensity of their negative emotions but still have difficulty controlling their attention or regulating their responses. They suffer from a cycle of increased pain from the shame and guilt that follow such impulsive actions they acted on to relieve their emotional pain.
DSM-V Final Diagnosis
The signs present in Maggie’s case indicate all the criteria in the diagnosis for Borderline Personality Disorder, which requires five of the following nine criteria to be met: Frantic efforts to avoid real or imagined abandonment; unstable and intense interpersonal relationships, characterized by alternating between extremes of ideation and devaluation; identity disturbance: markedly and persistently unstable self-image or sense of self; impulsivity in at least two areas that are potentially self-damaging areas (e.g., promiscuity, communicating with strangers and possible predators online, and running away); recurrent suicidal/ dangerous threats and attempts; affective instability due to marked reactivity of mood (e.g. episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days); chronic feelings of emptiness; inappropriate, intense anger or difficulty controlling her anger; transient, stress related paranoid ideation or sever dissociative symptoms (APA, 2013). The disturbances in Maggie’s behavior and affect ’causes clinically significant impairment’ in social and academic functioning, including school expulsion, family turmoil, and lack of friends (APA, 2013).
Assessment instruments that measure borderline personality symptoms should be included for Maggie’s case (Zanarini, 1989)like he Diagnostic Interview for Borderline Patients (DIB-R) is a semi structured clinical interview that consist of 132 questions and observation using 329 summary statements. The test looks at the four areas of functioning associated with borderline personality disorder, including Affect ,Cognition , Impulse action patterns, and Interpersonal relationships (Zanarini et al, 1989). The Structured Clinical Interview (now SCID-II) yields decent indications of the disorder, as it uses the language of the DSM-V in 12 groups of questions corresponding to the Axis II 12 personality disorders (zaarini et al, 2005).
Diagnosis
Axis I: 315.9 Unspecified neurodevelopmental disorder; V71.09
Axis II 301.83 Borderline personality disorder; V.69.9 Problem related to lifestyle;
R41.83 borderline intellectual functioning
Axis III No diagnosis
Axis IV: Problems with education, primarysupport group, and social environment.
Axis V: GAF = 51; some danger of hurting self or others
Etiology of Borderline Personality Disorder
There appear to be multiple pathways of affective instability and distinguished risk factors associated specifically to the development of BPD over other personality and mood disorders (Zanarini & Frankenburg, 1997). Genetic influences, neurobiology, upbringing, culture, and so forth can be conceptualized as precipitating factors , as it is unknown if they are either causal or mediating influences. Zanarini and Frankenburge’s (1997) ‘tripartite model’ of Borderline personality disorder suggest that the disorder is made up of complex combinations of three factors: (1) traumatic exposure, (2) vulnerability to a ‘hyperbolic’ temperament, and (3) a triggering serious of evens that set off borderline personality symptoms.
Social and Cultural Factors
Rapid social change, societal disruption, and normlessness, as presented by the lack of social structure and useful roles, appear to be important risk factors in the development of BPD (Paris, 1997). In regard to etiology there exists an important tension between viewing culture as having a direct influence on the development or exacerbation of BDP. At the same time, sociocultural factors may also act as a protective factor against the development of certain psychopathologies (Alarcon & Leetz, 1998).For instance, in Western Cultures the value placed on self-accomplishment and independence could be conceptualized as having a significant effect on exacerbating feelings of isolation, emptiness, and other factors related to identity disturbances, seen in BPD(Alarcon & Leetz, 1998). Further, idealization and devaluation are easily fostered in cultures where authority figures are idealized without question (Alarcon & Leetz, 1998). Conversely, BPD is less common in traditional cultures’ where the value is placed on compliance and cooperation. Paris (1997) argues that in developing societies, factors that have a particular emphasis on community resources and extended family networks, with strong family ties, are protective against the development of a personality disorder.
Parenting and attachment
The earliest relationship experiences sculpt the personality, shaping how one feels about themselves, and determines the extent to which we’re able to forge trust in others. Researchers found that early separations from parents (1 to 3 months) were more frequently observed in BPD patients (Zanarini et al, 1989), as BPD patients are more likely to display angry withdrawing patterns of attachment and compulsive care-seeking patterns. At its core, borderline personality exacerbates separation -indication issues, signifying acute abandonment issues that began in the first years of life (Bateman & Fonagy, 2004). Inadequate bonding with the birth mother or a disapproving father tend to start this personality in a downward spiral; any painful deficits in nurturing care and attention throughout childhood, perpetuate and reinforce this original disturbance (Gunderson, 2006) Additional research considers that parental over-involvement is important to the disorder. Within this dynamic attachment figures are often perceived to be unavailable, uncaring or overprotective (Gunderson, 2006). Individuals from families that cohere around a rigid denial of problems or exhibit a high degree of discord appear to be most vulnerable. The intensely confusing and paradoxical behavior patterns of the borderline are justified by this rational as simply defenses that were adopted growing up, to adapt to those kinds of experiences in their childhood home (zanarini et al, 2005.
Sources of Vulnerability
Trauma
The impact of sustained trauma or abuse has been shown to have long-term effects on the individual’s neurobiological make-up (Bateman & Fonagy, 2004).While it is problematic to assume a linear link between BPD and childhood exposure to trauma, early history of trauma is markedly reported higher in individuals with BPD (Bateman & Fonagy ,2004). Zanarini and colleagues (2005) reported that the risk of developing BPD was 14 times higher in those reporting childhood sexual abuse than physical abuse, prevalent in other PDS. Not all patients with BPD have histories of trauma and only small minorities of people who experience trauma develop BPD.
Biological Factors
Genetic Influences
Although there are no clear biological markers for BPD, links between BPD and genetic predisposition have been confirmed (Torgerson et al, 2000). The best fitting model for BPD had a heritability of 0.69, one of the highest indicators that genetic differences explain the variability in liability underlying BPD. Genetic studies on personality indicate that personality traits are more or less 50% heritable, leaving the remaining 50% to external factors (Zanarini et al 1997).
Neurochemistry
A number of neuroimaging studies, found in the works of Herpertz, Dietrich, Wenning, Krings, Erberich, Willmes, & Sass (2001) on borderline personality have reported findings of deficits in the serotonergic system and reductions in regions of the brain involved in the regulation of stress responses and emotion. Repeated studies show these abnormalities to be particular causal of that particular impulsive aggression and high level of sensation-seeking behavior as seen in borderline personalities. (Bateman & Fonagy, 2004).
The hippocampus and amygdala tends to be smaller and more active in people with BPD, as it is in people with post-traumatic stress disorder (PTSD) (Chapman & Gratz, 2007).Since the amygdala generate all emotions, including negative ones, this unusually strong activity may explain the heightened sensitivity, and unusual intense displays of these emotions in others (Herpertz et. al , 2001).The prefrontal cortex is known to mediate executive functioning and regulate emotional arousal, and tends to be less active in people with BPD. The relative inactivity of the prefrontal cortex might explain the difficulties people with BPD experience in regulating their emotions and responses to stress (Chapman & Gratz, 2007). The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production tends to be elevated in people with BPD, causing them to experience a greater biological stress response, explaining their greater vulnerability to irritability (Chapman & Gratz, 2007). Increased cortisol production is also associated with an increased risk of suicidal behavior. From a neurological perspective, the noradrenergic abnormalities are valuable in explaining why BPD patients tend to be highly sensitive and responsive to real and benign stimuli (Herpertz, et al, 2001)