A. Epidemiology

1. Characteristic pervasive pattern of instability of four areas:
   1. Affect regulation
   2. Impulse control
   3. Interpersonal relationships
   4. Self-image
2. Women affected 30%
3. Affects 1-2% of general adult population (1.8% in USA)
4. Likely higher incidence in children and teenagers (~10%)
5. Increased use of mental health resources
6. Types of Borderline Personality
   1. Affective
   2. Impulsive
   3. Aggressive
   4. Dependent
   5. Empty

B. DSM-IV Diagnosis

1. At least 5 of the following 9 criteria required (in any category)
2. Affective Criteria
   1. Affective instability due to marked reactivity of mood (includes: intense episodic dysphoria, irritability, or anxiety lasting a few hours, rarely more than a few days)
   2. Chronic feelings of emptiness
   3. Inappropriate, intense anger or difficulty controlling anger
3. Cognitive Criteria
   1. Transient, stress-related paranoid ideation or severe dissociative symptoms
   2. Identity disturbance: markedly and persistently unstable senlf-image or sense of self
4. Forms of Impulsivity
   1. Impulsivity in at least 2 areas that are potentially self-damaging (includes: spending, sexual behavior, substance abuse, reckless driving, binge eating)
   2. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
5. Interpersonal Criteria
   1. Frantic efforts to avoid real or imagined abandonment
   2. Pattern of unstable and intesnse interpersonal relationships characterized by alternating between extremes of idealization and devaluation

C. Causal Factors

1. Poorly Understood
2. Genetic factors likely contribute
3. Adverse childhood experiences (such as physical and/or sexual abuse)
4. Emotional Dysregulation and Impulsivity
5. Leading to dysfunctional and self-injurious behaviors

D. Treatment Overview

1. Pharmacotherapy and psychotherapy recommended
2. Psychotherapy in Borderline Personality (Box 2 from [2])
   1. Typically not brief
   2. Strong helping relationship between patient and therapist
   3. Clear roles and responsibilities between patient and therapist
   4. Therapist active and directive, not a passive listener
   5. Patient and therapist mutually develop hierarchy of priorities
   6. Therpist conveys empatic validation plust need for patient to control their behavior
   7. Limit setting, preferably mutually agreed
   8. Flexibility needed as new circumstances, including stresses, develop
   9. Concomitant individual and group approaches used
3. Pharmacotherapy targeted to symptoms
   1. Cognitive and perceptual problems respond to low dose neuroleptics
   2. Atypical neuroleptics such as olanzapine (Zyprexa®) or respiridone very effective
   3. Anxiety or depression responds to SSRIs and other antidepressants
   4. Mood stablilizers such as valproate or carbamazepine

References

1. Lieb K, Zanarini MC, Schmahl C, et al. 2004. Lancet. 364(9432):463
2. Oldham JM. 2002. JAMA. 287(8):1029