People with borderline personality disorder may experience intense mood swings and feel uncertainty about how they see themselves. Their feelings for others can change quickly, and swing from extreme closeness to extreme dislike. These changing feelings can lead to unstable relationships and emotional pain.
People with borderline personality disorder also tend to view things in extremes, such as all good or all bad. Their interests and values can change quickly, and they may act impulsively or recklessly.
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Borderline personality disorder is usually diagnosed in late adolescence or early adulthood. Occasionally, a person younger than age 18 may be diagnosed with borderline personality disorder if symptoms are significant and last at least a year.
Borderline personality disorder often occurs with other mental illnesses, such as post-traumatic stress disorder (PTSD). These co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with symptoms of the disorder. For example, a person with borderline personality disorder also may be more likely to experience symptoms of major depression, PTSD, bipolar disorder, anxiety disorders, substance abuse, or eating disorders.
Borderline personality disorder historically has been viewed as challenging to treat. But with newer, evidence-based treatment, many people with this disorder experience fewer and less severe symptoms, improved functioning, and better quality of life. It is important for patients with borderline personality disorder to receive treatment from a licensed mental health professional. Other types of treatment, or treatment from a provider who is not appropriately trained, may be ineffective or dangerous.
Many factors affect the length of time it takes for symptoms to improve once treatment begins. It is important for people with borderline personality disorder and their loved ones to be patient and receive support during treatment.
NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions, including borderline personality disorder. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lists ten personality disorders that are divided into three clusters, clusters A, B, and C. Borderline personality disorder (BPD) is a cluster B disorder that is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect and behavior. Borderline personality disorder causes significant impairment and distress and is associated with multiple medical and psychiatric co-morbidities. Surveys have estimated the prevalence of borderline personality disorder to be 1.6% in the general population and 20% in the inpatient psychiatric population. This activity examines the presentation and evaluation of borderline personality disorder and highlights the role of the interprofessional team in its management.
Objectives:Identify the epidemiology of borderline personality disorder.Describe the presentation of a patient with borderline personality disorder.Outline the treatment options available for borderline personality disorder.Explain interprofessional team strategies for improving care coordination and communication to advance the management of borderline personality disorder and optimize patient outcomes.Access free multiple choice questions on this topic.
A personality disorder is a disorder involving a rigid and unhealthy pattern of thinking. Personality disorders are prevalent in the general population and more so in clinical populations. In the pediatric population, all personality disorders can be diagnosed, except antisocial personality disorder, as long as the pathologic behavior has been present for a year or more. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lists ten personality disorders divided into the 3 clusters (A, B, and C).[1] Borderline personality disorder (BPD) is 1 of 4 cluster-B disorders that include borderline, antisocial, narcissistic, and histrionic. Borderline personality disorder (BPD) is characterized by hypersensitivity to rejection and resulting instability of interpersonal relationships, self-image, affect, and behavior.[2] Borderline personality disorder causes significant impairment and distress and is associated with multiple medical and psychiatric co-morbidities. Surveys have estimated the prevalence of borderline personality disorder to be 1.6% in the general population and 20% of the psychiatric inpatient population.[3]
In contrast, obsessive-compulsive personality disorder (OCPD) appears to be the most prevalent personality disorder, with rates around 5% of the general population in some studies.[4] Patients with borderline personality disorder have been shown to utilize extensive treatment resources and are at increased morbidity and mortality compared with the general population. This is perhaps the reason why borderline personality disorder has been studied more extensively than other personality disorders.
Borderline personality disorder is multifactorial in etiology. There is a genetic predisposition. Twin studies show over 50% heritability (greater than that for major depression).[5] Twin studies performed in 2000 and 2008 both demonstrated higher concordance of the rate of borderline personality disorder for monozygotic versus dizygotic twins. Environmental factors that have been identified as contributing to the development of borderline personality disorder include primarily childhood maltreatment (physical, sexual, or neglect), found in up to 70% of people with BPD, as well as maternal separation, poor maternal attachment, inappropriate family boundaries, parental substance abuse, and serious parental psychopathology.
There are many theories about the development of borderline personality disorder. In the mentalizing model of Peter Fonagy and Anthony Bateman, borderline personality disorder is the result of a lack of resilience against psychological stressors. In this framework, Fonagy and Bateman define resilience as the ability to generate adaptive re-appraisal of negative events or stressors; patients with impaired re-appraisal accumulate negative experiences and fail to learn from good experiences.[6] In the biosocial model popularized by Dr. Marsha Linehan, genetic vulnerability interacts with a "chronically invalidating environment" to produce the constellation of borderline personality disorder symptoms. In another theory, borderline personality disorder arises from the inability to regulate effect and the lack of formation of appropriate coping mechanisms in response to stress.[7] Otto Kernberg theorized that lack of integration in the early maternal relationship led to borderline personality disorder.[8] Kernberg hypothesized that the infant experiences the maternal figure in a dichotomous framework, the loving and nurturing mother who provides for the child and the punishing, hateful mother who deprives the child. This contradiction causes intense anxiety and, if not integrated into a more moderate unitary concept, ultimately leads to the development of splitting. The term "splitting" refers to the defense mechanism in which the patient cannot form a realistic view of another person. At any given time, the other person is viewed as entirely good or entirely bad. This inability to view others as having both positive and negative attributes impairs personal relationships.
Neuroimaging studies have identified differences in the amygdala, hippocampus, and medial temporal lobes in patients with borderline personality disorder. Such studies also suggest that patients with borderline personality disorder misattribute negative emotions (fear, anger, disgust) to neutral faces more so than controls or other patients, despite having the perception of happy and upset faces equivalent to those groups. Neurobiological studies have suggested that impaired neuropeptide function, particularly serotonin, may be present in patients with borderline personality disorder. On neuropsychological testing, a meta-analysis published in 2005 showed that patients with borderline personality disorder had lower performance on neurocognitive testing in the following domains: attention, cognitive flexibility, learning and memory, planning, speed processing, and visuospatial abilities.[9]
Large, nationwide epidemiologic studies published in 2007 and 2008 estimated the point prevalence of borderline personality disorder in the general population at 1.6%, with a lifetime prevalence of 5.9%. No significant difference in rates of borderline personality disorder was found between females and males in the general population. In the clinical setting, however, the ratio of females to males has been reported as 3:1. These studies challenged previous reports that borderline personality disorder was more prevalent in women. The prevalence of borderline personality disorder in the psychiatric outpatient population has been estimated at 11%, and in the psychiatric inpatient population, as high as 20%. Multiple studies examining the relationship between ethnicity and borderline personality disorder have not produced similar results.[10][11]
The pathophysiology of borderline personality disorder is likely a combination of genetic predisposition combined with early childhood environmental factors and neurobiological dysfunction. A greater understanding of neurobiology and, specifically, neurotransmitter dysfunction may lead to improved therapeutic options for treating borderline personality disorder. A recent study published in 2015 examined the role of oxytocin in the regulation of social reward and empathy networks as a contributing cause of borderline personality disorder and other personality disorders. Specifically, serotonin dysregulation reducing the sensitivity of the 5HT-1A receptor may contribute to borderline personality disorder. Increased rates of learning disorders, attention-deficit/hyperactivity disorder, and neurocognitive deficits, as well as abnormal electroencephalographic findings, have also been reported in patients with borderline personality disorder. 2ff7e9595c
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