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Borderline Personality Disorder
 
Permission graciously given by the author to reproduce this paper: 
 
Borderline Personality Disorder

Doyle-Delrosso
2007

     According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-lV-TR) Borderline Personality Disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image, and affect (moods) and marked impulsivity beginning in early childhood and present in a variety of contexts, as marked by five of the following.

1.  Frantic efforts to avoid real or imagined abandonment.
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 (spending, sex, substance <>abuse, reckless driving, binge eating)<>
5.  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6.  Affective instability due to a marked reactivity of mood (intense episodic dysphoria, <>irritability, or anxiety usually lasting a
     few hours and only rarely a few days). 

7.  Chronic feelings of emptiness.
8.  Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights).
9.  Transient, stress-related paranoid ideation or severe dissociative symptoms.

Several conditions are frequently comorbid with borderline personality disorder, including
 
Mood Disorders

Substance Abuse related disorders 

Panic and Anxiety Disorders

Eating disorders especially Bulimia Nervosa 

Post-Traumatic Stress Disorders 

Gender Identity Disorder


     Borderline personality disorder (BPD) can be defined as disorder that might stem from genetics and severe childhood trauma/abuse that is associated with post traumatic stress (PTS) or complex

Post traumatic stress (C-PTS) although recent research has indicated that BPD can also be and related to nueroendocrine dysfunction.
 Onset: Some feel the onset of BPD is at puberty, some feel earlier. Most will not diagnose until adulthood claiming the angst of puberty can mimic some BPD. Some are diagnosing the BPD in puberty now. Others use the Oppositional Defiance Disorder and Conduct Disorder diagnosis until adulthood.

Genetics: According to (Silverman & Torgersen et al, 1994, 2000) although studies of family and twins with BPD suggest that while the disorder itself maybe heritable, the prominent features of impulsivity appears to run in families. An overview of the existing literature suggests that genes influence traits similar to BPD but it’s too early to say to what extent genes also influence BPD, but because personality traits generally show a strong genetic influence, this should also be true for BPD. The assumption of equally shared environment may also predispose an individual to BPD. After reviewing the material it is my belief that BPD is a disorder that may involve environment, genetics, biochemistry and childhood trauma. The use of biologic markers in the evaluation of borderline personality disorder (BPD) patients has also been researched. Many patients with Axis II BPD have coexisting Axis I diagnoses of which depression is the most commonly reported. Biologic markers have not aided in the diagnosis of BPD, but some markers, particularly EEG sleep, are not only abnormal in BPD, but also appear to discriminate Axis I depression from other Axis I disorders.

Physiology of BPD:  (Goodman & New, 2000) have preformed numerous studies that have demonstrated that decreased central serotonergic activity is associated with measures of impulsive aggression in patients with personality disorders. Studies of personality characteristics (Bouchard, 1994) have shown suicidality, affective instability and impulsivity to be heritable. Gene studies provide a window into what specific receptors might be involved in the control of aggression. A selection of genes involved in serotonin functioning comes from the observation that decreased serotonergic activity has been associated with impulsive aggression. Several gene products involved in serotonin synthesis, reuptake, metabolism and receptors have been identified: tryptohan hydroxylase plays an important role in the growth and development of infants and in the biosynthesis of serotonin, since tryptohan plays such an important role in brain of infant development the hypothesis of severe child abuse has been associated with individuals exhibiting BPD. The borderline personality disordered individual appears to have a lower threshold to environmental stimuli, resulting in impulsive aggressive behaviors. In addition, their propensity towards self directed aggression is also greater. Their personality may in part be organized around these aggressive outbursts or traits and intimacy becomes difficult because of their chronic irritability and anger. Their motor disinhibition is associated with a difficulty in mastering aggression and effectively separating or individuating from others they depend on during the course of their development.There is good evidence that the tendency to impulsive aggression has psychobiologic substrates. The serotonin system is a behavioral suppressive system that is involved in modulation of appetite, mood, temperature regulation, and a variety of vegetative functions. Serotonergic neuronal activities increase during repetitive self-directed behaviors and may decrease when an individual attends to novel events in their environment. Lesions of serotonergic neurons, result in disinhibited aggression, for example, in rats the killing of mice placed in their vicinity. Rats with lesions of the serotonergic system cannot learn to extinguish or dampen bar pressing behavior where the bar pressing was previously rewarded and is currently punished. In other words, these animals appear to have a deficit in the suppression of punished behaviors. According to (Carlson, 2001) serotonin is concentrated in certain areas of the brain; the hypothalamus while the cortex and cerebellum contain low concentrations. Like most neurotransmitters, it is stored in granules inside nerve endings, and is thus not exposed to inactivation by monoamine oxidases until it is released into the synaptic space between nerves. When a serotonin containing nerve fires, serotonin is released and can bind to any one of a series of at least 14 distinct downstream serotonin receptors (5-HT receptors). Release of serotonin or other stored neurotransmitters can also be induced by alkaloids such as reserpine, which have been used as tranquilizing agents in the treatment of nervous and mental disorders. Although pharmacological doses of serotonin produces a decrease with regard to impulsive aggression finding conclude a low CSF 5 –HIAA and decreased neuroendocrine response to serotonergic agents. Studies with individuals have also suggested that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of stress and/or drugs like alcohol. Areas in the front of the brain (pre-frontal area) act to damp the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion. Also associated with BPD is intermitted depression, which might also be related to a low level of dopamine that is a neurohormone, released by the hypothalamus. Recent research has suggested that there may be a link between depression and neurogenesis of the hippocampus. This horseshoe-shaped structure is a center for both mood and memory. Loss of neurons in the hippocampus is found in depression and correlates with impaired memory and dysthemic mood. The hippocampus regains mass when exposed to treatments that increase brain serotonin, and when regrown, mood and memory tend to be restored. The emotional regulation is caused by a dysfunction of the limbic area in the brain, which controls emotion. The emotion regulation is such that a feeling of being slighted becomes RAGE versus anger, or feeling alone and unloved becomes severe anxiety thus the “I love you, don’t leave me” syndrome. This triggers depression. This malfunction can also trigger other areas of the brain leading to anxiety, disassociation and psychosis. Impulsive aggression is also a core feature of BPD. The borderline patients engages in self-damaging acts, including self-mutilating behavior and suicide attempts, particularly when frustrated or disappointed. These may be considered as instances of self directed aggression. BPD persons are also prone to angry outbursts that interfere with the stability of their relationships. They are impulsive, reflected in behavior such as binge eating, gambling, substance abuse, promiscuity, or reckless driving.

     The depression and uncontrolled emotional state is referred to as dysphoria. This dysphoric response, suggests that the cholinergic system may play a role in mediating the dysphoric affects of borderline personality disorder patients. Interestingly, the degree of dysphoric responses is correlated with affective instability and related traits that reflect personality disorders of impulsivity and aggression. The reason that child abuse is so prevalent in the BPD history is that in many cases one or both parents are mentally ill. The mentally ill tend to congregate together, thus limiting the gene pool”. In regard to child abuse those who are diagnosed and treated for their illnesses tend not to abuse their children

Psychologically: Borderline Personality Disorder (BPD) is a diagnosis that has many different meanings depending on the tradition or discipline from which it is viewed. Psychoanalytically oriented practitioners focus on its intrapsychic structures and defense mechanisms such as "splitting," while interpersonally oriented clinicians understand the borderline in terms of disturbances in their interpersonal relatedness. Psychopharmacologies tend to understand borderline clients in terms of atypical affective disorders, or impulse related disorders and treat according to these target symptom areas. According to (Conklin & Bradley el al, 2006) the two psychobiologic vulnerabilities or temperamental predispositions are affective instability and impulse aggression. The borderline personality disordered individual appears to have a lower threshold to environmental stimuli, particularly frustrating stimuli, resulting in disinhibited impulsive aggressive behaviors. In addition, their propensity towards self directed aggression is also greater. The individual with BPD is exquisitely affectively sensitive to environmental shifts, particularly in their interpersonal sphere, so that they react with feelings of, for example, rage and despair and separation, humiliation and fury at a setback at relationships, friends and family. It is likely that this highly sensitive affective thermostat is present from a very early age and may apparently have genetic as well as early environmental. This affective sensitivity during the course of early development may prove a challenge to the successful mastery of the developmental tasks of childhood and adolescence. For example, an infant who is very sensitive to separation or bodily pain may cry more frequently and be more difficult to soothe when mother or other caretaker leaves, the baby may cry loudly and persistently. For a depressed or affectively sensitive parent, such a child can present a challenge. As the child grows older, these crying spells may turn into temper tantrums. For even the most empathic parent, there may be a temptation to respond to these tantrums with either excessive indulgence or at other times inattention of neglect. For the child, these inconsistent responses may constitute a sort of "intermittent reinforcement" making their temper tantrums more likely. The temper tantrums may be the antecedents to affective storms that we may see in the borderline patient during adulthood when threatened with a potential loss of a relationship or feelings of abandonment. There are some suggestions that there may be biologic underpinnings to this affective sensitivity or instability.

Genetic studies (Bohman, 1984) of monozygotic and dizygotic twins suggest that there may be genetic factors for these dimensions of emotional reactivity and impulsive aggression. Family members of BPD patients are more likely to demonstrate affective instability or impulsivity, although not necessarily both. Impulsivity and aggression seem to be heritable in studies of normal twins as well. It is noteworthy that in the studies of prolactin responses to fenfluramine, blunted prolactin response to fenfluramine in a patient is a better predictor of impulsivity and aggression in their relatives than was impulsive aggression as a behavior in itself in the patient. These results would suggest that what is inherited is not the behavior, but an alteration in serotonergic system that may at times be expressed in a propensity to impulsive aggression. Patients with BPD tend to show greater responses to pharmacological agents that may induce affective changes. It is suggested that borderline patients with affective instability respond to administration of physostigmine, a cholinesterase inhibitor that prevents the breakdown of acetylcholine, with marked feelings of negative mood or dysphoria. BPD person’s personality may in part be organized around aggressive outbursts or traits and intimacy becomes difficult because of their chronic irritability and anger. Their motor disinhibition is associated with a difficulty in mastering aggression and effectively separating or individuating from others they depend on during the course of their development. In humans, reductions in serotonergic activity are associated with impulsive aggressive behavior. According to (Krystal, 1994) neuroendocrine responses to the serotonin releasing agent fenfluramine are blunted, suggesting reduced serotonergic activity in patients with BPD. They are specifically associated with those criteria of BPD that reflect impulsive aggressive traits that reflect impulsive aggressive traits such as angry outbursts, impulsivity, and self-damaging acts. They are not associated with interpersonal or affective related traits. The prolactin response to fenfluramine is highly inversely associated with self-ratings of irritability and assaultiveness, with the greatest reductions in serotonergic activity being associated with the highest reported irritability and aggression. Thus, the association between reduced serotonergic activity and aggression does not seem specific to BPD, but rather to impulsivity and aggression which may be found in other personality disorders such as antisocial personality disorder as well. In fact, studies of antisocial personality disorder patients also reported blunted prolactin responses to fenfluramine have a demonstrated increased history of abuse, there is no doubt that the history of abuse is common in personality disorder patients, particularly in BPD patients. According to (Bohman et al, 1984) suggest that abuse may sensitize or alter the activity of the stress system such as the hypothalamus pituitary-adrenal (HPA) axis and may have long- term effects on the monoamine systems as well. Some studies even suggest that certain kinds of trauma or early abuse may actually cause structural changes in a central part of the brain involved in emotional memories, the hippocampus.

Environment: It is also clear that the environment plays an important role in the development of borderline personality disorder and may even influence the biology of impulse and affect regulation. One prominent environmental antecedent to BPD is a history of abuse or neglect. Many studies suggest a high proportion of borderline patients have experienced some form of abuse, particularly sexual abuse, during their development. While it is not clear that BPD over other personality disorders always have a demonstrated increased history of abuse, there is no doubt that the history of abuse is common in personality disorder patients, particularly in BPD patients. According to (Bohman et al, 1984) suggest that abuse may sensitize or alter the activity of the stress system such as the hypothalamus pituitary-adrenal (HPA) axis and may have long- term effects on the monoamine systems as well. Some studies even suggest that certain kinds of trauma or early abuse may actually cause structural changes in a central part of the brain involved in emotional memories, the hippocampus. People who have been diagnosed with BPD often report feeling neglected during childhood. Clients often report feeling alienated or disconnected from their families. Often they attribute the difficulties in communication to their parents. Families providing reasonable nurturing and caring environments may as well see the symptoms of BPD given preference to the physiology factors involved with the disorder. The best explanation is that there seems to be a combination of both environmental factors and a sensitive, emotional child who has difficulty interpreting the world including the meaning of his caregivers.

Treatment: During an acute phase hospitalization may be required to prevent self-destructive behaviors and to stabilize the client. It is useful to eliminate or reduce the use of alcohol and recreational drugs. A healthy diet, a regular work and leisure routine and good sleep hygiene should also be encouraged.

Cognitive Behavior Therapy (CBT): CBT is important to learn because it teaches the client the client to be able to identity his thoughts, feelings and circumstances before and after an emotional upset. CBT plays a critical role in helping the patient and therapist assess the determinants, or high-risk situations, that are likely to lead to distorted thought processing and provides insights into some of the reasons the individual may be reacting to specific situations as they do (to cope with interpersonal difficulties). BPD helps the client challenge core beliefs, which adversely affect self-perception and the ways in which the client interacts with the world. CBT is emotional neutral and structured than psychoanalytic therapy whereas social rehabilitation process are needed. Cognitive therapy like behavior therapy focuses primarily on the here and now. Cognitive and behavioral strategies can be combined often improving raid results in behavior. The first three steps analyse the process by which a person has developed irrational beliefs and may be recorded in a three-column table.

Activating Event or objective situation which is the event that leads to some type of high emotional response or dyfunctional thinking.

Beliefs in the second colume is where the client writes down the negative thoughts that have occurred to them

Consequence would be in the third column and is for the negative feelings and dysfunctional behaviors that have occurred. The negative thoughts of the second column are seen as a connecting bridge between the situation and the distressing feelings. The third column C is next explained by describing emotions or negative thoughts that the client thinks are caused by A.

CBT emphasizes the role of thinking in how we feel and what we do. CBT stresses the fact that thoughts, rather than people or events, cause our negative feelings. CBT is a structured collaboration between therapist and client and often calls for homework assignments.

<>Dialectical Behavior Therapy (DBT) has been used with great success treating persons with BPD.

 (DBT) is a psychosocial treatment developed by Marsha M. Linehan specifically to treat individuals with borderline personality disorder.While DBT was designed for individuals with borderline personality disorder it can also be used for other disorders.Theoretically, DBT hypothesizes that the behaviors characterizing BPD arise from a transaction between the patient's emotional vulnerability, lack of emotion modulation skills, and an invalidating environment. The effect of this interaction, and the key problem in BPD, is thought to be “pervasive emotional dysregulation”. Most everyone becomes emotionally dysregulated at certain times of their lives, typically in situations of high intensity. The purpose of the DBT skills is to help the client get into a state of mind referred to in DBT as “wise mind”. Wise mind is the middle ground in the dialectic between “rational mind” and “emotional mind”.To be too far on the side of rational mind would mean focusing only things such as facts and figures; ignoring and suppressing emotion.To be too far on the side of emotional mind would mean being so blinded by strong emotions that one would not be able to consider the facts. Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense.They can be angry, intensely frustrated, depressed, or anxious.This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavioral therapy skills for emotion regulation include:identifying and labeling emotions, identifying obstacles to changing emotions, reducing vulnerability to emotion mind, increasing positive emotional events, increasing mindfulness to current emotions, taking opposite action and applying distress tolerance techniques. The therapist relates to the patient in two dialectically opposed styles. The primary style of relationship and communication is referred to as 'reciprocal communication', a style involving responsiveness, warmth and genuineness. The alternative style is referred to as 'irreverent communication’. This is a more confrontational and challenging style aimed at bringing the patient up with a jolt in order to deal with situations where therapy seems to be stuck or moving in an unhelpful direction. It will be observed that these two communication styles form the opposite ends of another dialectic and should be used in a balanced way as therapy proceeds. The therapist should try to interact with the patient in a way that is: 1. Accepting of the patient as she is but which encourages change. 2. Centered and firm yet flexible when the circumstances require it. 3. Nurturing but benevolently demanding. The dialectical approach is here again apparent. There is a clear and open emphasis on the limits of behavior acceptable to the therapist and these are dealt with in a very direct way. The therapist should be clear about his or her personal limits in relations to a particular patient and should as far as possible make these clear to her from the start. This type of therapeutic process begins with skill training which are four modules focusing on four types of skills.  

(Linehan, 1993).

<>Core mindfulness skills

Interpersonal effectiveness skills

Emotion modulation skills

Distress tolerance skills

The 'core mindfulness skills' are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.

The 'interpersonal effectiveness skills' which are taught focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.

'Emotion modulation skills' are ways of changing distressing emotional states and 'distress tolerance skills' include techniques for putting up with these emotional states if they cannot be changed for the time being.

 

Supportive therapy may be required two or three times a week to stabilize mood, maintain control over self-destructive behaviors, assure medication compliance and provide counseling on reducing situational stresses. According to (Dewald, 1994) supportive therapy is the idea of "lending ego" which derives from the psychoanalytic tradition; and broadly conceived, it refers to a therapist’s functioning as an "auxiliary ego" for the patient. The client is allowed to use or "borrow" the therapist’s presumably well-working mind and psychological capacities in order to enhance his or her own. In effect, the patient is encouraged to think like the therapist, who presumably represents a good role model for mental health. What sorts of ego functions are "lent" in supportive therapy? Often of key importance is reality testing, since it is difficult to negotiate one’s environment successfully if one cannot distinguish between reality and fantasy. Other important ego functions that may be lent include problem analysis and solving, affect modulation, impulse control ("think before you act"), and, perhaps, the functions subsumed under the recently popular term of "emotional intelligence", which include interpersonal awareness, empathy, and social skills. Talking about issues is often very beneficial in supportive therapy, but in the long run, discussion alone is no substitute for action. Only through the successful testing of new interpersonal behaviors or skills, the conquest of specific fears, or the mastery of feelings of inadequacy will the patient truly be convinced that he or she is capable in changing behavior and faulty thought processing. The setting of specific, concrete, achievable behavioral goals serves another important function: it enables the behavioral principle of "shaping." With supportive therapy patient, behavioral approaches, behavioral rehearsal, role-playing, relaxation, graded exposure, visualization and imagery, are often the most useful in helping the patient to reach his or her goals. Many of these techniques are enumerated and detailed by (Beck, 1993) and by (Linehan, 1993). The patient may also be encouraged to become active through the assignment of homework to be completed between sessions, this regard, stressing the importance of potential difficulties.

Family Therapy can determine stresses and interventions to reduce stress and provide information on the nature, management and expected course of the illness. Especially with the more severely or chronically mentally ill, there may be great benefit to similarly educating the patient’s family, significant others, key friends, employer, or various social agencies. Such persons can serve as "observing egos" and "auxiliary egos" for the client. At the same time, however, the client’s wishes, autonomy, and confidentiality must be respected. Except in cases of emergency (e.g., imminent risk of physical danger to self or others), the therapist should ask the client permission to speak with others about his or her case. Parent and spouses can feel misjudged and unfairly criticized when a person of BPD blames them for their behavior. The usual behavior of a BPD is to “project” blame on to another individual for their actions creating feeling of guilt and helpless to individual members within the family circle. Family members need to be educated about the borderline diagnosis and prognosis and what are expectable treatment outcomes. Such interventions can reduce stress, open communication, and relieve family burdens. Family therapy provides the family the ability to solve problems and express thoughts and emotions. Family members may explore roles, rules and behavior patterns in order to spot issues that contribute to conflict. Family therapy may help to identify the family's strengths, such as caring for one another, and weaknesses, such as an inability to confide in one other. Families may not understand the roots of the illness or how best to offer help. Sometimes families have such deep-rooted family conflicts that conversations ultimately erupt into arguments and members are left with hurt feelings, decisions unmade, and the rift grows wider. Family therapy can help you pinpoint specific concerns and assess how your family is handling the problems that are presented by person’s diagnosis with BPD.

 Psychotherapy Therapy: One form of therapy that is psychodynamic in nature, is known as transference-focused psychotherapy (TFP). This therapy is geared primarily at understanding the underlying causes of the patient's borderline condition and working to build newer, healthier ways of thinking and behaving for the patient. TFP is a treatment based on psychoanalytic concepts designed especially for borderline patients. This twice-per-week individual psychotherapy has been developed over a period of decades and is described in a treatment manual. Although it dates back many years, TFP combines many of the elements described in the recently published Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association. TFP places special emphasis on the assessment and on the treatment contract and frame. The setting up of the contract and frame has a behavioral quality in that boundaries are established to deal with the likely threats both to the treatment and to the patient's well being that may occur in the course of the treatment. The client is engaged as a collaborator in setting up these conditions. One distinguishing feature of TFP in contrast to many other treatments for BPD is the belief in a deep psychological structure (structure of the mind) that underlies the specific symptoms of BPD. The focus of treatment is on a fundamental split in the patient's mind that divides perceptions of self and others into extremes of bad and good. This internal split determines the patient's way of experiencing self and others and the environment; it determines the patient's experience of reality. Since this internal split determines the nature of the patient's perceptions, it leads to the specific symptoms of BPD: chaotic interpersonal relations and impulsive self-destructive behaviors. This is one of the most prevalent symptoms of person’s experiencing BPD tend to transfer their distorted thought processing on to others and blame all of the negative behavior to others without taking any responsible for their own actions. Psychotherapy can develop a stable working relationship with the client and provide a safe holding environment to reduce maladaptive, impulsive behaviors during of patterns of situational stresses. Treatment should be organized around BPD as a disorder of attachment and mentalizing capacity, which can be viewed in thinking about others as having an inner world with feelings and conceptions different from one's own and targeted four main areas: identification and appropriate expression of affect, development of stable internal representations, formation of a coherent sense of self, and capacity to form secure relationships. Interventions can be structured according to a hierarchy. The first aim is to help the client to improve affect control, followed by targeting internal representations through a focus on mentalizing capacity. Finally the sense of self and the detail of the dynamics of the relationship can be investigated through a transference exploration in individual and group sessions. The development of the treatment plan should be) well-structured; 2) devote considerable effort to enhancing compliance; 3) have a clear focus, whether that focus, is a problem behavior or an aspect of interpersonal relationship patterns; 4) coherent to both therapist and client, 5) encourage a powerful attachment relationship between therapist and client, enabling the therapist to adopt a relatively active rather than a passive stance; and 6) treatment should be well-integrated with other services available to the client. The internal split occurs in the earliest years of human development when strong emotional experiences are internalized in the individual's mind and become established as “object relations dyads”, or templates of particular types of relationships. These dyads, or templates, combine a specific representation of the self and of the other linked by an affect, or strong feeling. Different dyads stemming from different situations represent specific images of the self and of the other connected by different affects. These dyads are not exact, accurate representations of historical reality, but may be distorted, since the memories are encoded in moments of intense affect.

Group therapy, which may be effective in a few patients. May help to reduce the patient's sense of isolation. 

Patient Education Therapy should be given on appropriate information of mood stabilizer to accommodate fluctuations in stress levels and to minimize total burden of medication.  Which is the most common form of therapy used; it is designed to enhance the patient's understanding of specific manifestations, and to help the patient to develop less impulsive and emotionally over-reactive responses.

Pharmacological Treatment: According to (Paris, 2005) antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used in low doses when there are distortions in thinking and, at low doses, for anxiety. Patients with marked mood swings sometimes benefit from certain drugs ordinarily used to treat epilepsy like mood stabilizers. Patients with severe depression or eating disorders may benefit from antidepressant medication. Small doses of the neuroleptic drugs typically used for schizophrenia sometimes help borderline patients in periods of severe stress. Lithium is sometimes helpful, and may make it possible to use lower doses of other drugs. Minor tranquilizers or sedatives should be considered only with caution since they are dangerously habit forming. Neuroleptics: While low-dose neuroleptics have long been used to target impulsive symptoms in BPD psychiatrists have been rightly cautious about prescribing agents with so many side effects. Studies of haldoperidol in this population have shown that patients tend to stop taking it and that short-term effects are not maintained on 6-month follow-up However, atypical neuroleptics such as risperidal and olanzapine have milder side effect profiles, and 3 studies have supported the use of olanzapine in BPD which seems to have a primary effect on impulsivity. Nevertheless, atypicals also have side effects, and there are data suggesting that these agents provoke obesity in this population 

Selective Serotonin Reuptake Inhibitors (SSRIs)

<>Fluoxetine, fluvoxamine, paroxetine, sertraline 

SSRIs have been widely used to treat BPD, usually with the aim of targeting the prominent depressive symptoms seen in this population. While some research suggests that SSRIs do reduce mood disturbance the results fail to match the dramatic effects of antidepressants in classical depression. Other studies suggest that SSRIs are most effective in reducing anger and impulsive symptoms High dosages (for example, 60 to 80 mg of fluoxetine daily) may yield a specific effect on self-mutilation but patients have difficulty tolerating these levels.

There has also been research on MAOIs and on tricylcic antidepressants in BPD, but their side effects and potential lethality on overdose have not encouraged wide use.

Although it is unusual today to see a patient with BPD who is not on an antidepressant, this practice rests more on clinical lore than on evidence from controlled trials. Antidepressants seem to “take the edge off” the symptom of BPD, but one never sees remissions of the personality disorder itself. Side effects of the (SSRI) selective serotonin reuptake inhibitors include: transient anxiety,

 Gastrointestinal effects, tremors, sleep disturbances, headache, dyskinesias, and sexual dysfunction.

Mood Stabilizers are drugs that may be useful in enhancing mood stability, decrease impulsivity and improve cognitive performance in borderline personality disorder include low-dose atypical antipsychotic agents risperidone, olanzapine, quetiapine, amisulpride, valproate, lithium 

Selective serotonin reuptake inhibitors (SSRI’s)  fluoxetine, fluvoxamine, paroxetine sertraline

The evidence for the use of mood stabilizers in BPD is equivocal. The only controlled study of lithium in BPD failed to demonstrate efficacy, and few clinicians would wish to use a drug that is so dangerous on overdose. Carbamazepine may have some value in reducing impulsivity but it is also dangerous on overdose. A controlled trial found that valproate had only marginal efficacy in BPD A more extensive trial and one other report suggest that this agent has overall effectiveness for reducing impulsive aggression in personality disorders but is less useful for affective instability. Better results reported in another trial of valproate were limited to BPD patients with comorbid bipolar disorder (BD11) (that is, those with clear-cut hypomanic episodes). A recent RCT for lamotrigine in BPD found that its main effect was to reduce aggression. A recent controlled trial of topiramate showed that, like other mood stabilizers, its main effect on mood in BPD patients is anger reduction. More research on mood stabilizers is needed in large samples to determine whether they are consistently useful in this population. Present evidence suggests that they may be more useful for impulsivity and aggression than for mood stabilization itself. These conclusions may seem surprising, since these agents are often thought of as targeting affective instability. While this is a key feature of BPD that distinguishes it from other personality disorders, the mood stabilizers that are useful in BD do not seem to work in the same way in BPD. It is therefore possible that the emotional dysregulation seen in BPD patients is an entirely different phenomenon from that seen in bipolar spectrum disorders. As with antidepressants, the indications for mood stabilizers should not be limited by their name, since they show a broader spectrum of action.

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