Borderline personality disorder (BPD) is a common, serious mental illness easily defined by the considering the five domains of dysregulation: emotional, behavioural, relational, cognitive and self identity.
Typically in Victoria, the Diagnostic Statistical Manual – 5 (DSM-5) is used to diagnose BPD. The International Classification of Diseases provides another way of understanding BPD. The easiest way to see BPD is to use the description provided in the 5 Domains.
DSM – 5
The current diagnostic criteria set for Borderline Personality Disorder (BPD) is taken from the American Psychiatric Association’s DSM-5 (APA, 2013). Patients must meet five of nine criteria in order to be diagnosed with BPD. Patients who partially, but incompletely, meet this criteria set may be considered to have borderline personality traits or features.
ICD – 10
The ICD-10 Classification of Mental and Behavioural Disorders, World Health Organisation, Geneva was first compiled in 1992 and is updated annually.The ICD-10 in section F60.3, describes Emotionally Unstable (Borderline) Personality Disorder as being either the ‘Impulsive Type’ or the ‘Borderline Type’.
The predominant characteristics of the Impulsive Type are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.
The predominant characteristics of the Borderline Type include several of the characteristics of emotional instability and also the person’s own self image, aims and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self harm (although these may occur without obvious precipitants).
The 5 Domains
The easy way to understand BPD is to use the concept of the 5 Domains as described by Marsha Linehan who developed the first and most researched effective treatment, Dialectical Behaviour Therapy (DBT).
Emotional dysregulation - people with BPD have difficulties managing their emotions and they can be highly sensitive. Often this dysregulation appears as anger.
Behavioural dysregulation - if emotions are running high, then behaviour can be easily affected. A common response to this might be self harm which might be used to distract the person from severe psychic pain, or to try to attract attention to this distress that feels unbearable.
Relational dysregulation - people with BPD will often have difficulties with their relationships with close family. They may hold their loved ones overly close or reject them completely. They may struggle to develop strong personal relationships.
Cognitive dysregulation - often highly intelligent, a person with BPD may struggle with every challenges and find it difficult to achieve their goals. Acting impulsively may be seen as a factor in cognitive dysregulation.
Identity dysregulation - People with BPD struggle with self identity. They are often overwhelmed with shame and a deep seated sense of aloneness.
It is commonly accepted that there are genetic risk factors and environmental risk factors. However there are a range of differing theories about how BPD develops. A study of the data indicates that BPD appears to be moderately heritable and to involve a complex interplay between biological and environmental factors.
Interestingly, social factors in BPD are suggested by indirect evidence. Thus far, there have been no cross-cultural studies of BPD, although characteristic symptoms such as recurrent suicide attempts are less common in traditional societies, in which there is little change from one generation to the next, but are on the increase in modern societies and in societies undergoing rapid change.
The term was first coined in 1938 with a description of the diagnostic criteria by the American psychoanalyst Adolph Stern. He described the people with BPD as being on border of neuroses and psychosis.
There is much debate about the appropriateness of the name, which will probably continue. While the DSM 5 continues to use the descriptor Borderline Personality Disorder, so will we here in Victoria.
The US National Dept of Health and Human Services Report to Congress of 2011 acknowledges a prevalence of 5.9% for BPD based on the research of 34,600 plus people in face to face diagnostic interviews, with little difference in between men and women (Huang et al. 2008).
Earlier in 2000, using the International Classification of Diseases criteria for Personality Disorders (PDs) in a phone interview as part of the Australian National Survey of Mental Health and Wellbeing , Australian researchers estimated a prevalence of 6.5% for personality disorders.
In 2008 an epidemiological study of PDs as defined by DSM and structured clinical interviews by experienced diagnosticians, suggested an overall average of 11.39%. (Lenzenweger. 2008)
Using these figures as a guide we can estimate that approximately 6% of Victorians, about 350,000 people, have BPD. A further 700,000 family members are directly affected. This equates to 1 person in 6 being directly affected by this serious mental illness in Victoria.
Earlier estimates regarding the prevalence of Borderline Personality Disorder (BPD) in the general population have suggested a 1 – 2% rate of lifetime occurrence (APA, 2000). This has also been found in several studies of community samples (Coid et al., 2006; Samuels et al., 2002; Torgersen et al., 2001).
A variety of explanations have been proposed to account for this disparity. For example, it has been suggested that it is due to differences in the presentation of symptoms among men and women. Johnson and colleagues (2003) found that women diagnosed with BPD tend to exhibit the more dramatic aspects of BPD symptoms such as intense and unstable emotionality and self-harm behaviours, while men present more subtle antisocial and impulsive behaviours. The prevalence difference may also reflect biases held by mental health providers when diagnosing BPD. Skodol and Bender (2003) argue that the general belief that BPD is more prevalent in women than in men creates a bias toward identifying the disorder in women while exploring other disorders for men. There are suggestions also that females seek help more readily.