What is a personality disorder?
An individual’s personality is defined by their specific patterns of thinking, expressing and experiencing emotion and relating to others. Modern theories of personality agree that it comprises several continuous dimensions which are defined by specific traits that exist across a spectrum.
Patient visiting psychiatrist doctor. Image Credit: Elnur / Shutterstock
One example is the dimension of introversion-extroversion, which is defined by traits such as reserved-outgoing and solitude-companionship.
As with physical characteristics such as height and weight, most people fall somewhere between the two extremes.
A personality disorder can be understood as an extreme personality type which interferes with interpersonal relationships and causes distress to the individual or those around them.
People with personality disorders are more likely to possess undesirable personality traits and experience them to a greater degree; personality disorder is a problematic extension of normal personality traits. The disorders are arranged into three clusters based on their primary difficulties.
Cluster A represents the eccentric disorders (including schizoid and paranoid), Cluster B represents the erratic disorders (such as antisocial and narcissistic) whilst Cluster C describes the fearful and anxious personality disorders (including obsessive-compulsive and avoidant).
Borderline personality disorder (BPD) belongs to Cluster B and is the commonest form of personality disorder, affecting approximately 2% of the general population. It is present among 20% of all patients hospitalized in psychiatric units.
The DSM-5 lists nine diagnostic criteria for BPD, 5 of which must be present to receive a diagnosis. These include:
- Emotional instability including intense anguish or irritability,
- Inappropriate and intense outbursts of anger,
- Chronic feelings of emptiness,
- Engaging in damaging acts such as reckless driving, substance misuse or risky sexual behavior,
- Recurrent suicidal ideation or threats, or self-harming behavior such as cutting, hitting or burning oneself,
- A markedly and persistently unstable sense of self or self-image,
- Paranoid thoughts or periods of dissociation,
- Engaging in frantic behavior to avoid real or imagined abandonment,
- Intense and unstable relationships, alternating between over and undervaluing loved ones.
Additionally, for a diagnosis of personality disorder, these symptoms must be problematic (causing distress), persistent (usually beginning in adolescence and persisting into adulthood) and pervasive (affecting functioning in multiple personal and social contexts).
The stigma of personality disorder
Historically, BPD has been regarded as a highly incapacitating lifetime disorder. Owing to the prevalence of BPD observed in acute psychiatric care, people with the disorder are often seen by healthcare professionals during periods of crisis, leading to the assumption that recovery is not possible. This group of patients have, as a result, been heavily stigmatized.
Although the prognosis for BPD in both the short and medium term is poor, causing severe psychological suffering and debilitating impairments to general functioning, long term prognosis is more promising.
One longitudinal study of 362 individuals with BPD showed that over 85% of the sample were in remission 10 years later. The likelihood of recovery is greatly enhanced by access to appropriate treatment.
Treatment options in BPD
Although there are no medications that have been specifically licensed and approved for the treatment of BPD, several classes of psychiatric medication are useful in the management of specific symptoms of the disorder.
Antipsychotics: A systematic review and metanalysis of 26 randomized controlled trials, found that antipsychotics can be beneficial in the treatment of BPD, especially for those patients with cognitive or perceptual disturbance such as paranoia or dissociative episodes. Furthermore, they can a beneficial impact on anger and hostility, emotional lability and impulse control.
Mood stabilizers: Mood stabilizers belong to a class of psychiatric medication which are used in the treatment of mood disorders characterized by extreme emotional lability (rapid and exaggerated shifts in mood). Traditionally used in the treatment of bipolar disorder, mood stabilizers have been shown to reduce symptoms such as irritation, anger, and mood fluctuation in BPD.
Antidepressants: Although research has failed to demonstrate an impact on the core features of BPD the co-occurrence of BPD with major depressive disorder is high suggesting that the majority of those diagnosed with BPD would benefit from antidepressant treatment.
Long-term ‘talking therapies’ is a crucial element of treatment in BPD and is recommended as first-line treatment. The evidence base for psychotherapeutic interventions in BPD suggests two adaptations of cognitive behavioral therapy are effective.
Dialectical Behavioral Therapy (DBT): Stemming from the assumption that emotional dysregulation is the core difficulty in BPD, DBT focuses on learning skills to manage dysregulation and reduce dysfunctional methods of managing strong emotions. Delivered as a combination of individual and group therapy, DBT focuses on four skills: mindfulness (observing events and emotions without judgement); interpersonal effectiveness (successfully asserting needs and navigating conflict in relationships); distress tolerance; and emotion regulation. DBT currently has the largest empirical evidence base for successful treatment of BPD, with numerous randomized controlled trials demonstrating its efficacy.
Mentalization-Based Therapy (MBT): MBT focuses on improving the ability to make sense of the thoughts, feelings and beliefs of oneself and others, particularly in situations which evoke strong emotions and dysfunctional behaviors. The effects of MBT have been mostly documented in the United Kingdom, with multiple randomized controlled trials showing benefits in adult and adolescents although evidence is emerging of its effectiveness beyond its environment of origin.
Importance of getting help
Identification and treatment for patients with BPD is essential. Not only do patients with BPD engage in behaviors of self-harm, but they are far more likely to attempt suicide and successfully complete suicide compared to the general population.
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