EMOTIONALLY UNSTABLE (BORDERLINE) PERSONALITY DISORDER: DIAGNOSIS AND COMPLICATIONS

Diagnostic Features: 

Emotionally Unstable (Borderline) Personality Disorder is a condition characterized by impulsive actions, rapidly shifting moods, and chaotic relationships. The individual usually goes from one emotional crisis to another. Often there is dependency, separation anxiety, unstable self-image, chronic feelings of emptiness, and threats of self-harm (suicide or self-mutilation). This disorder is only diagnosed when these behaviors become persistent and very disabling/distressing. 

Complications:

Completed suicide occurs in 8%-10% of individuals with this disorder, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent job losses, interrupted education, and broken marriages are common. 

Comorbidity:

Very stressful or chaotic childhoods are commonly reported (e.g., physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation). Mood disorders, Substance-Related Disorders, Eating Disorders (usually Bulimia), Posttraumatic Stress Disorder, Attention-Deficit/Hyperactivity Disorder, and other Personality Disorders frequently co-occur with this disorder. 


Associated Laboratory Findings:

No laboratory test has been found to be diagnostic of this disorder. 

Prevalence:

The prevalence of Emotionally Unstable (Borderline) Personality Disorder is about 2% of the general population. It is seen in 10% of psychiatric outpatients, and 20% of psychiatric inpatients. This disorder is more frequent in females (about 75%) than males. Emotional instability and impulsivity are very common in adolescents, but most adolescents grow out of this behavior. Unfortunately, for some, this emotional instability and impulsivity persists and intensifies into adulthood; thus they become diagnosed with this disorder. 

Course:

The course of this disorder is quite variable. The most common pattern is one of chronic instability in early adulthood. This disorder is usually worse in the young-adult years and it gradually decreases with age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. After about 10 years, about half of individuals with this disorder no longer meet the full criteria for Borderline Personality Disorder. 

Familial Pattern:

This disorder is about 5 times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for Substance-Related Disorders, Antisocial Personality Disorder, and Mood Disorders.

BIPOLAR DISORDER: RISK FOR SUICIDE

Bipolar Disorder and Risk for Suicide
It is important to note that an estimated 15% to 20% of patients who suffer from bipolar disorder and who do not receive medical attention commit suicide. The risk is greater in the following individuals:
•In a 2001 study of bipolar disorder I disorder, more than 50% of patients attempted suicide; the risk was highest during depressive episodes.
•Some studies have suggested that the risk with bipolar disorder II patients is even higher than it is in patients with bipolar disorder I or major depression disorder
•Patients with mixed mania, and possibly when it is marked by irritability and paranoia, are also at particular risk.
•Many young pre- and early adolescent children with bipolar disorder are more severely ill than are adults with the disease. According to a 2001 study, 25% of children with bipolar disorder are seriously suicidal. They have a higher risk for mixed mania (simultaneous depression and mania), multiple and frequent cycles, and a long duration of illness without well periods.


Rapid cycling, although a more severe bipolar disorder variation, does not appear to increase the suicide risk for patients with bipolar disorder.

Thinking and Memory Problems in Those With Bipolar Disorder
A 2000 study reported that bipolar disorder patients had varying degrees of problems with short- and long-term memory, speed of information processing, and mental flexibility. Medications used for bipolar disorder, however, could have been responsible for some of these abnormalities and more research is needed to confirm or refute these findings.

Behavioral and Emotional Effects of Manic Phases on the Patient
A small percentage of bipolar disorder patients demonstrates heightened productivity or creativity during manic phases. More often, however, the distorted thinking and impaired judgment that are characteristic of manic episodes can lead to dangerous behavior, including the following:
•A person may spend money with abandon, causing financial ruin in some cases.
•Angry, paranoid, and even violent behaviors are not uncommon during a manic episode.
•Some people are openly promiscuous.
Often such behaviors are followed by low self-esteem and guilt, which are experienced during the depressed phases. During all stages of the illness, patients need to be reminded that the mood disturbance will pass and that its severity can be diminished by treatment.

Bipolar Disorder and Substance Abuse
Cigarette smoking is prevalent among bipolar patients, particularly those who have frequent or severe psychotic symptoms. Some experts speculate that, as in schizophrenia, nicotine use may be a form of self-medication because of its specific effects on the brain; further research is necessary.

Up to 60% of patients with bipolar disorder abuse other substances (most commonly alcohol, followed by marijuana or cocaine) at some point in the course of their illness.

The following are risk factors for alcoholism and substance abuse in bipolar disorder patients:
•Having mixed-state episodes rather than ones of pure mania.
•Being a man with bipolar disorder.
Effects of Untreated Bipolar Disorder on Loved Ones
Patients do not work out their negative behaviors (e.g., spending sprees or even becoming verbally or physically aggressive) in a vacuum. They have a direct effect on others around them. It is very difficult for even the most loving families or caregivers to be objective and consistently sympathetic with an individual who periodically and unexpectedly creates chaos around them.

Many patients and their families, therefore, cannot admit that these episodes are part of an illness and not simply extreme, but normal, characteristics. Such denial is often strengthened by patients who are highly articulate and deliberate and can intelligently justify their destructive behavior, not only to others, but also to themselves.

Often family members feel socially alienated by the fact of having a relative with mental illness, and they conceal this information from acquaintances. (This is particularly true if the patient is female and lives away from home.) People with more education are more likely to feel ostracized by their acquaintances than are those with less education.

Economic Burden
The economic burden of bipolar disorder is significant. In 1991, the National Institute of Mental Health estimated that the disorder cost the country $45 billion, including direct costs (patient care, suicides, and institutionalization) and indirect costs (lost productivity and involvement of the criminal justice system). In spite of the obvious need for professional help, access to medical therapies is not always available for patients with bipolar disorder. In one major survey, 13% of patients had no insurance and 15% were unable to afford medical treatment.

Bipolar's Association with Physical Illnesses
Diabetes. Diabetes is diagnosed almost three times more often in people with bipolar disorder than it is in the general population. A 2002 study reported that 58% of bipolar patients were overweight, with 26% meeting the criteria for obesity. Being overweight is a significant risk factor for diabetes and so it may be the common factor in both diseases. Drugs used to treat bipolar also pose a risk for weight gain and diabetes. Common genetic factors have also been implicated in diabetes and bipolar disorder, including those causing a rare disorder called Wolfram syndrome and those that regulate carbohydrate metabolism.

Migraine Headaches. Migraines are common in patients with a number of mental illnesses, but they are particularly common among bipolar II patients. In one study, 77% of bipolar II patients had migraines while only 14% of bipolar I had this headache, suggesting that difference biologic factors may be involved with each bipolar form.

Hypothyroidism. Hypothyroidism (low thyroid levels) is a common side effect of lithium, the standard bipolar treatment. However, evidence also suggests that bipolar patients, particularly women, may be at higher risk for low thyroid levels regardless of medications. It may in fact be a risk factor for bipolar disorder in some patients.

BORDERLINE PERSONALITY DISORDER: SIGNS AND SYMPTOMS

Most people with a borderline personality disorder are women and it's estimated 1-2% of American adults have Borderline Personality Disorder. Borderline personality becomes evident in early adulthood but becomes less common in older age groups.

People with borderline personality are unstable in their self-image, moods, behavior, and interpersonal relationships. The Merck Manual states "their thought processes are more disturbed than those of people with an antisocial personality, and their aggression is more often turned against the self. They are angrier, more impulsive, and more confused about their identity than are people with a histrionic personality."


People with a borderline personality often report being neglected or abused as children. Consequently, they feel empty, angry, and deserving of nurturing. They have far more dramatic and intense interpersonal relationships than people with cluster A personality disorders (odd or ecentric personality disorders such as paranoid personality disorder, schizoid personality disorder). When they fear being abandoned by a caring person, they tend to express inappropriate and intense anger. People with a borderline personality tend to see events and relationships as black or white, good or evil, but never neutral

When people with a borderline personality feel abandoned and alone, they may wonder whether they actually exist (that is, they do not feel real). They can become desperately impulsive, engaging in reckless promiscuity , substance abuse, or self-mutilation. At times, they are so out of touch with reality that they have brief episodes of psychotic thinking, paranoia, and hallucinations.

According to the Merck Manual, people with a borderline personality commonly visit primary care doctors. Borderline personality is also the most common personality disorder treated by therapists, because people with the disorder relentlessly seek someone to care for them. However, after repeated crises, vague unfounded complaints, and failures to comply with therapeutic recommendations, caretakers, including doctors, often become very frustrated with them and view them erroneously as people who prefer complaining to helping themselves.

DSM IV Diagnostic Criteria for Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
•frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
•a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization 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 (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
•recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
•affective instability due to a marked reactivity of mood (e.g., intense 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 anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
•transient, stress-related paranoid ideation or severe dissociative symptoms
Causes of Borderline Personality Disorder
The cause of Borderline Personality Disorder is unknown but may be a result of genetic and environmental factors, brain abnormalities or a combination. Many people with borderline personality disorder have a history of childhood abuse, neglect and separation from caregivers or loved ones. And since personality is shaped in childhood, these factors could play a significant role in the development of Borderline Personality Disorder.

Risk factors for developing Borderline Personality Disorder include:
•Hereditary predisposition. You may be at a higher risk if a close family member, a mother, father or sibling, has the disorder.
•Childhood abuse. Many people with the disorder report being sexually or physically abused during childhood.
•Neglect. Some people with the disorder describe severe deprivation, neglect and abandonment during childhood.

BIPOLAR DISORDER: MEDICATIONS AND TREATMENT

Bipolar disorder is a serious mental illness. People who have it experience dramatic mood swings. They may go from overly energetic, "high" and/or irritable, to sad and hopeless, and then back again. They often have normal moods in between. The up feeling is called mania. The down feeling is depression.
Bipolar disorder can run in families. It usually starts in late adolescence or early adulthood. If you think you may have it, tell your health care provider. A medical checkup can rule out other illnesses that might cause your mood changes.

Untreated, bipolar disorder can result in damaged relationships, poor job or school performance, and even suicide. However, there are effective treatments: medicines and "talk therapy". A combination usually works best.



What are mood stabilizers?
Medications are considered mood stabilizers if they have 2 properties:

1. they provide relief from acute episodes of mania or depression, or prevent them from occurring; and
2. they do not worsen depression or mania or lead to increased cycling.

No Iframes Lithium, divalproex and carbamazepine have been shown to meet this definition; the first 2 are the best established and most widely used. Divalproex and carbamazepine were originally developed as anticonvulsants for the control of epilepsy, another brain disorder. Other available medications that are undergoing research as promising mood stabilizers include several new anticonvulsants and the newer "atypical" antipsychotics. Electroconvulsive therapy (ECT), discussed later, is also considered a mood stabilizing treatment.

Lithium (brand names Eskalith, Lithobid, Lithonate)
The first known mood stabilizer, lithium, is actually an element rather than a compound (a substance synthesized by a laboratory). Lithium was first found to have behavioral effects in the 1950s and has been used as a mood stabilizer in the United States for 30 years. Lithium appears to be most effective for individuals with more "pure" or euphoric mania (where there is little depression mixed in with the elevated mood). It is also helpful for depression, especially when added to other medications. Lithium appears to be less effective in mixed manic episodes and in rapid-cycling bipolar disorder.
Monitoring blood levels of lithium can reduce side effects and ensure that the patient is receiving an adequate dose to help produce the best response. Common side effects of lithium include weight gain, tremor, nausea, and increased urination. Lithium may affect the thyroid gland and the kidneys, so that periodic blood tests are needed to be sure they are functioning properly.

Divalproex (brand name Depakote)
Divalproex has been used as an anticonvulsant - to treat seizures - for several decades. It has also been extensively researched as a mood stabilizer in bipolar illness. Divalproex is equally effective in both euphoric and mixed manic episodes. It is also effective in rapid cycling bipolar disorder and for individuals whose illness is complicated by substance abuse or anxiety disorders.

Unlike other mood stabilizers, divalproex can be given in relatively large initial doses for acute mania, which may produce a more rapid response. Common side effects of divalproex include sedation, weight gain, tremor, and gastrointestinal problems. Blood level monitoring and dose adjustments may help minimize side effects. Divalproex may cause a mild liver inflammation and may affect the production of a type of blood cell called platelets. Although it is quite rare for there to be any serious complications from these potential effects, it is important to monitor liver function tests and platelet counts periodically.

Other anticonvulsants used as mood stabilizers

• Carbamazepine (Tegretol, Carbatrol). Although fewer clinical studies support the use of carbamazepine, it appears to have a profile similar to divalproex. It, too, has been available for many years, and is effective in a broad range of subtypes of bipolar illness and in both euphoric and mixed manic episodes. Carbamazepine commonly causes sedation and gastrointestinal side effects. Because of a rare risk of bone marrow suppression and liver inflammation, periodic blood testing is also needed during carbamazepine treatment, just as during treatment with divalproex. Because carbamazepine has complicated interactions with many other medications, careful monitoring is needed when it is combined with other medications.
  
• Lamotrigine (Lamictal). Lamotrigine is a relatively new medication. Recent research suggests that it can act as a mood stabilizer, and may be especially useful for the depressed phase of bipolar disorder. One serious risk of lamotrigine use is that 3 out of every 1,000 individuals (0.3%) taking the medication develop a serious rash. The risk of rash can be lowered by increasing the dosage very slowly. Aside from the risk of rash, lamotrigine tends to have fewer troublesome side effects overall, but can cause dizziness, headaches, and difficulties with vision.
  
• Gabapentin (Neurontin). Gabapentin has become popular as a mood stabilizer, although there has been relatively little research on its use in bipolar disorder. It appears especially helpful in reducing anxiety. One strength of gabapentin is that it is unlikely to interact with other medications, so that it can be easily added to other mood stabilizers to augment their effect. Side effects of gabapentin can include fatigue, sedation, and dizziness.
  
• Topiramate (Topomax). Preliminary research suggests that this new anticonvulsant may be helpful in mania. One side effect of topiramate may actually be an advantage. Unlike many of the other mood stabilizers, topiramate does not appear to cause weight gain and may actually help people lose weight. Other side effects may include sedation, dizziness, and cognitive slowing or memory difficulties. It should avoided by people who have had kidney stones.
  
  What are antidepressants?
  Antidepressants treat the symptoms of depression. In bipolar disorder, antidepressants must be used together with a mood stabilizing medication. If used without a mood stabilizer, an antidepressant can push a person with bipolar disorder into a manic state.
  Many types of antidepressants are available with different chemical mechanisms of action and side effect profiles. Most research with antidepressants has been done in people with unipolar depression - people who have never had a manic episode. In unipolar depression, the available medications are about equally effective. There has been little research on the use of antidepressants in bipolar disorder, but most experts consider the following 3 types to be first choices:
  
• Bupropion (Wellbutrin)
• Selective serotonin reuptake inhibitors: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft) No Iframes
• Venlafaxine (Effexor)

If these do not work, or if they cause unpleasant side effects, the other choices are:

• Mirtazapine (Remeron)
• Nefazodone (Serzone)
• Monoamine oxidase inhibitors: phenelzine (Nardil), tranylcypromine (Parnate). These are very effective but also require you to stay on a special diet to avoid dangerous side effects.
• Tricyclic antidepressants: amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), imipramine (Tofranil), nortriptyline (Pamelor). Tricyclics may be more likely to cause side effects or to set off manic episodes or rapid cycling.

What are antipsychotic medications?
Antipsychotic medications are used to control psychotic symptoms, such as hallucinations or delusions, that sometimes occur in very severe depressive or manic episodes.

Antipsychotics can be used in 2 additional ways in bipolar disorder, even if no psychotic symptoms are present. They may be used as sedatives, especially during early stages of treatment, for insomnia, anxiety, and agitation. Researchers also believe that the newer atypical antipsychotic medications have mood stabilizing properties, and may help control depression and mania. Antipsychotic medications are therefore often added to mood stabilizers to improve the response in patients who have never had psychotic symptoms. Antipsychotics may also be used alone as mood stabilizers when patients cannot tolerate or do not respond to any of the mood stabilizers.There are 2 kinds of antipsychotics: older antispychotics (often called "typical" or conventional antipsychotics ) and newer antipsychotics (often called atypical antipsychotics). One serious problem with the older antipsychotics is the risk of a permanent movement disorder called tardive dyskinesia (TD). Older antipsychotic medicines may also cause muscle stiffness, restlessness, and tremors. The newer "atypical" antipsychotics have a much lower risk of causing TD (roughly 1% per year) and movement and muscle side effects. Because of this, the newer atypical antipsychotics are usually the first choice in any of the situations when an antipsychotic is needed.

Five atypical antipsychotics, are currently available:

1. olanzapine (Zyprexa)
2. quetiapine (Seroquel)
3. risperidone (Risperdal)
4. clozapine (Clozaril)
5. aripiprazole (Abilify)

As mentioned earlier, research has shown that these atypical antipsychotics have mood stabilizing properties. Common side effects of the atypical antipsychotics include drowsiness and weight gain. Although it is very effective, clozapine is not a first choice medication because it can cause a rare and serious blood side effect, requiring weekly or biweekly blood tests.
Examples of conventional antipsychotics include older medications such as haloperidol (Haldol), perphenazine (Trilafon), and chlorpromazine (Thorazine). Although they are not usually a first choice, the older medications can be helpful for patients who do not respond to or have troublesome side effects with the newer atypical antipsychotics.

POST-TRAUMATIC STRESS DISORDER (PTSD): CAUSES AND DIAGNOSTIC

Post-traumatic Stress Disorder is a severe reaction to an extremely traumatic event. The person can actually experience the event (i.e. be in a plane crash) or be a witness to the event (i.e. rescue worker at a plane crash).

Over time and with psychological help, some people learn to cope with the aftermath of the event. However, for others, symptoms such as flashbacks and depression can become worse, lasting a long period of time, and seriously disrupting the person's life.


Sometimes symptoms do not begin until many months or even years after the traumatic event took place. If post-traumatic stress disorder has been present for 3 months or longer, it is considered chronic.

PTSD is an anxiety disorder which can affect both children and adults. About 7% of the population will develop PTSD in their lifetime; 5 million adults in the U.S. have PTSD during any given year.

Diagnostic Criteria for Post-traumatic Stress Disorder (PTSD)

The person has been exposed to a traumatic event in which both of the following were present:

• the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
• the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

The traumatic event is persistently reexperienced in one (or more) of the following ways:

• recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
• recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
• acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
• intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
• physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

• efforts to avoid thoughts, feelings, or conversations associated with the trauma
• efforts to avoid activities, places, or people that arouse recollections of the trauma
• inability to recall an important aspect of the trauma
• markedly diminished interest or participation in significant activities
• feeling of detachment or estrangement from others
• restricted range of affect (e.g., unable to have loving feelings)
• sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

• difficulty falling or staying asleep
• irritability or outbursts of anger
• difficulty concentrating
• hypervigilance
• exaggerated startle response

Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Causes of Post-traumatic Stress Disorder (PTSD)

Living through or seeing something that's upsetting and dangerous, psychological trauma, can cause PTSD. This can include:

• Being a victim of or seeing violence (kidnapping, torture, sexual abuse)
• The death or serious illness of a loved one
• War or combat
• Car accidents and plane crashes
• Hurricanes, tornadoes, and fires
• Violent crimes, like a robbery or shooting.

Studies indicate the amount of dissociation that directly follows a trauma predicts PTSD. Individuals who are more likely to dissociate during a traumatic event are considerably more likely to develop chronic PTSD.
There also seems to be a genetic component to post-traumatic stress disorder. PTSD runs in families. And, as with many psychological disorders, a person's temperament, brain chemistry and other environmental factors likely play a role in the development of PTSD. In addition, having an existing psychiatric disorder, a family history of depression, or a poor support system following a traumatic event are all risk factors for PTSD.