borderline personality disorder in the elderly a case study

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Borderline personality disorder and ageing: myths and realities

Affiliations.

• 1 Department of Humanities, University of Urbino 'Carlo Bo', Urbino, Italy.
• 2 University of Sydney, Faculty of Medicine and Health, Sydney Medical School, Nepean Clinical School, Sydney, Australia.
• PMID: 34812741
• DOI: 10.1097/YCO.0000000000000764

Purpose of review: Although mental health issues in ageing individuals have been receiving more attention, borderline personality disorder (BPD) in older adults and the elderly has been relatively neglected. This article aims to review the current state of knowledge about BPD in these age groups.

Recent findings: Studies have consistently reported decreasing prevalence rates of BPD among ageing individuals. This may be attributed to the ageing process itself and/or different clinical features due to which meeting the diagnostic criteria for BPD becomes more difficult. Ageing individuals with BPD often present in a way that makes them look 'atypical' compared to younger individuals with the same condition. In particular, this pertains to somewhat attenuated and less overt manifestations of impulsivity. However, the basic pattern of overall symptoms instability continues to characterize ageing individuals with BPD, in addition to depressive symptoms, feeling of emptiness, anger, unstable interpersonal relationships, turbulent responses when needs are not met, various somatic complaints and other symptoms.

Summary: Clinicians should be aware of different clinical features of BPD as patients get older. Diagnostic criteria for BPD may need to be revised to reflect this reality, allow accurate diagnosis and minimize the risk of overlooking BPD in ageing individuals.

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Borderline Personality Disorder in the Elderly: A Case Study

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Published  December  01, 1986

Article Information

Volume: 31 issue: 9, page(s): 859-860

Received: December   1985;

Issue published:  December 01  1986

DOI：10.1177/070674378603100914

Daniel J. Siegel , Gary W. Small

Vol 31, Issue 9, 1986

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Daniel J. Siegel, Gary W. Small

Vol 31, Issue 9, pp. 859 - 860

Issue published date: December-01-1986

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Personal Accounts: A "Classic" Case of Borderline Personality Disorder

• Lynn Williams

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As someone who once suffered world-class symptoms of borderline personality disorder that resulted in multiple admissions to hospitals, but who has since gone on to rejoin society, I can offer some perspectives on this disorder.

Misconceptions about borderline personality disorder

The first misconception most people have about borderline personality disorder is that its dramatic manifestations such as reckless or suicidal behavior are merely deliberate, manipulative attempts to get attention. That is not true. The distress is real.

For me, when I was acutely ill, no other options besides my suicidal behavior existed. I often fervently hoped each overdose would be the last or that finally someone would "see" how much help I needed. I had complete tunnel vision and couldn't envision yesterday or tomorrow. While having my stomach pumped in an emergency room or while running away from a psychiatric hospital, I would careen from high to low in euphoric bursts; I felt as if I was watching someone else. Even if the experience was unpleasant, which it usually was, I was unable to learn from it. Brief moments bordering on lucidity were too painful. It was as if part of me was asleep and I couldn't wake myself up, or was too afraid or felt too hopeless to wake myself up.

I was accused of intentionally reacting in certain ways and was once asked sarcastically by a doctor, "Is this enough attention for you?" But inside I was more like a frightened two-year-old than the cunning individual he thought I was. I couldn't see what I was doing. Mostly I felt desperate, with a longing to be permanently looked after, and I felt addicted to looking for help. I can explain these feelings only on reflection.

Some people believe people with borderline personality disorder "enjoy" it and don't want to get well. Wrong. I was out of control and couldn't have changed my behavior if I wanted to because I was looking for rescue. But each time the response from health care providers would be different. I felt, in a warped way, that their concern did clarify my existence, but my panic, fear, and anger took over when my racing thoughts and attempts to flee were stopped.

When I would overdose and when medical intervention, usually by force, was deemed necessary, I would feel temporarily hopeful, and then threatened, judged, and thwarted in meeting some sort of need. Oh, how I see the futility of it now. I was incapable of seeing it then, and I secretly wanted to be respected, liked, and approved of, but I didn't know how to attain these privileges or whether I was worthy of them in the first place.

How the disorder feels

The best way I have heard borderline personality disorder described is having been born without an emotional skin—with no barrier to ward off real or perceived emotional assaults. What might have been a trivial slight to others was for me an emotional catastrophe, and what would be a headache in emotional terms for someone else was a brain tumor for me. This reaction was spontaneous and not something I chose.

In the same way, the rage that is often one of the hallmarks of borderline personality disorder, and that seems way out of proportion to what is going on, is not just a "temper tantrum" or a "demand for attention." For me, it was a reaction to being overwhelmed by present pain that reminded me of the past. To put it simply, think of something that would really hurt you and multiply it by a hundred.

If several stressors occurred in sequence, I sometimes started to generalize, negatively. The past and the present became one. Feelings swept over me like one of those nets used to trap animals in the jungle—black, dark, persistent, and at times suicidal feelings. Those feelings, accompanied by flawed logic, fantasies of rescue, and a kind of self-preservation system gone awry created chaos in my mind. I would feel hopeless, my world would compartmentalize, and I'd enter an unremitting state of shock. The pain would seem interminable.

Thus the pain experienced by people with borderline personality disorder is not just a result of simple immaturity, a brilliant imagination, or the longings of a so-called spoiled child. We don't end up certified, in police lockups waiting to see a psychiatrist, or even dead because we're morally deficient. Our pain is real, but the equation creating that pain is faulty. Something is shut down in our brains that means we can't listen at first because we're in survival mode.

My longing for rescue made me, especially after I entered the treatment system, run, flee, turn to authorities for help, be chased. In fact, I fled from security (that is, I left the psychiatric unit), running away but still wanting to be caught, to be contained but not suffocated—primal feelings that I couldn't verbalize then. To say it was an altered state of consciousness is putting it mildly. All I can say now is that there was something I wanted to be gone but at the same time didn't wish to lose.

How mental health professionals can help

The most important thing is, Do not hospitalize a person with borderline personality disorder for any more than 48 hours. My self-destructive episodes—one leading right into another—came out only after my first and subsequent hospital admissions, after I learned the system was usually obligated to respond. Nothing that had happened to me before being admitted to a psychiatric unit for the first time could even approach the severity of the episodes that followed.

What I did after I entered the system was to survive using maladaptive tools as a result of knowledge I acquired in the hospital. The least amount of ill-placed reinforcement kept me going. It prevented me from having to make a choice to get well or even finding out that I wasn't as helpless as I believed myself to be.

In the community, a person with borderline personality disorder can discover how to live. Hospitalization activates needy feelings and perpetuates the patient's sick self-image in her own eyes and those of staff. I believe if you live with the lame, you learn to limp. I know I did. Hospitalization is too easy an "out," but episodes of self-harm may very well reduce or disappear if the patient knows the response will be minimal.

A person with borderline personality disorder is often just looking for reassurance rather than admission when she hints at or threatens suicide—she doesn't yet know how to directly and safely express her feelings. If she is admitted, however, she will probably regret it five minutes after she gets in. Without hospitalization, she can see that what seems beyond endurance usually is not. This realization has allowed me, albeit slowly, to grow and learn to cope. Tolerating pain and uncertainty is the only way this can happen.

The person with borderline personality disorder doesn't know how to wait, and a system that immediately responds doesn't give her a chance to soothe herself. Therefore, she continues to believe she is helpless. A man in an emergency room once said I would have to grow up and take care of myself. Reflecting the helplessness that I felt, I screamed at him, "I can't! . . . Don't you know that alone I'm going to die?" It was flawed but to me believable logic, with emotions literally blocking the intellect.

When you as a service provider do not give the expected response to these threats, you'll be accused of not caring. But what you are really doing is being cruel to be kind. When my doctor wouldn't hospitalize me, I accused him of not caring if I lived or died. He replied, referring to a cycle of repeated hospitalizations, "That's not life." And he was 100 percent right!

I would never have the life I have today if I had continued to get the intermittent reinforcement of hospitalization. The longer I stayed out of the hospital, the less I wanted to be in. The devastation I would have felt at supposedly losing my foundation of recovery would have been far worse than what I was feeling at the time. When I started to struggle to put my life together, sometimes all I had was that ever-growing time out of the hospital—which, with the exception of a short stay during the summer of 1997, has spanned five years—as something positive I could point to.

A word of advice to mental health professionals that cannot be stressed too strongly: don't define people with borderline personality disorder too strictly by any textbook limitations you have read. I have exceeded my doctor's expectations for improvement, and he doesn't know how far I can progress. For the most part I've stayed out of the hospital, maintain long-term full-time employment, live independently, have a motor vehicle, and plan to pursue further educational opportunities. If I—as one of the most chronic, regular, well-known, persistent visitors to emergency rooms in my community between the late 1980s and early 1990s, and as one of the most chronic hospital escapees, and as someone who was written off and told so—could triumph over borderline personality disorder to this extent, I'm sure other people with the disorder can at least improve the quality of their lives.

Someone answering to my name was once a terrified, angry person who was showing up in emergency rooms nearly every night and throwing up into a basin, or was being looked for regularly by the police when threatening suicide. Someone answering to my name also once fought nasogastric tubes and ran from nurses, doctors, police, and hospital security. But that wasn't the real me. That's not who I want to be.

Nor are the other people who are seen through the pathology of borderline personality disorder showing their real selves. As frustrating as these acutely ill people may be, please don't write them off. Maybe, just maybe, you'll be able to help one of them. I'm living proof that—over time—we can be helped.

Ms. Williams lives in eastern Canada and works full time in the legal system. She has written a resource manual and has made speeches to mental health professionals about her diagnosis. Send correspondence to her in care of Psychiatric Services, 1400 K Street, N.W., Washington, D.C. 20005. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.

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Personality Disorders in Older Age

• Chevelle Brudey , M.D., M.P.H.

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Personality disorders are among the most common mental disorders in older age and are associated with a range of negative outcomes in physical and emotional health as well as in interpersonal functioning. Several screening tools have been validated with older patients and can aid in diagnosis. The presence of a personality disorder is associated with increased risk of cognitive decline, and cognitive disorders may mimic personality disorders. As a result, an evaluation of cognitive function is an essential part of assessing for a personality disorder. Emerging evidence points to the promise of dialectical behavioral therapy and schema therapy for older patients with personality disorders. Second-generation antipsychotics and mood stabilizers have been found to be effective for some personality disorders in the general adult population, but no such studies have been conducted with older adults.

Clinical Context

The diagnosis of a personality disorder requires a pervasive pattern of maladaptive behavior that impairs functioning in at least two of the following domains: cognition, affect, interpersonal functioning, and impulse control (see Box 1 ). Personality disorders have their onset by adolescence or early adulthood. The observed impairment must not be better explained by another mental disorder or medical condition and should not be due to the effects of a substance. Traditionally, personality disorders have been categorized in clusters A (paranoid, schizoid, and schizotypal), B (antisocial, borderline, narcissistic, and histrionic), and C (avoidant, dependent, and obsessive-compulsive). The more recent dimensional classification relies on identification of dysfunctional personality functioning with dysfunctional personality traits. Dysfunctional personality traits are defined within these domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism ( 1 ).

Box 1. DSM-5 criteria for general personality disorder

Reprinted from the Diagnostic and Statistical Manual of Mental Disorders , 5th ed., Washington, DC, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric Association. Reprinted with permission.

Personality disorders are frequently considered in individuals with flagrantly and persistently maladaptive interpersonal relationships or obvious impulsivity. Health care providers may be less keen to diagnose a personality disorder in patients who do not present with significant interpersonal conflict. Patients with avoidant and dependent personality disorders have an extreme tendency toward conflict avoidance coupled with a compulsive drive to please others and habitual minimization of their own distress. In the health care setting, these patients are often respectful, conscientious, and adherent to treatment recommendations. As a result, the absence of interpersonal conflict between the patient and provider may decrease the provider’s suspicion of an underlying personality disorder. Among older adults, patients with cluster A and cluster B personality disorders may be dismissed as merely eccentric.

Ideally, the diagnosis of personality disorder will be made after a clinical interview, with information from the patient and from one or more reliable collateral informant(s) ( 2 ). Each of these sources provides unique, complementary information that aids diagnosis. A clinical interview alone is frequently insufficient to discover information pertinent to the diagnosis of a personality disorder, as patients are often unaware of disordered traits or may be unwilling to disclose vitally pertinent information. However, in practice, collateral information may be entirely unavailable or quite limited. Care must be taken, however, to establish chronicity of disordered thought patterns, affect, and behavior. Even in patients who do not meet the full criteria for a personality disorder on first evaluation, identifying dysfunctional personality disorder traits gives important clues to a patient’s overall functioning and can lay the foundation for a later diagnosis. Often, longitudinal clinical encounters are required to diagnose a personality disorder accurately.

Because of advances in recent decades, diagnosis of personality disorders in older adults can be aided by the use of standardized assessment tools ( 3 ). The Gerontological Personality Disorder Scale is a 16-item screening tool that has been validated with older adult outpatients. There are two versions of this screening tool, designed to be used by patients and informants, respectively. The Hetero-Anamnestic Personality Questionnaire (HAP) has been validated in older adults in long-term care. For the HAP, only an informant provides information. The Assessment of DSM-IV Personality Disorders has been found to be largely (but not entirely) age neutral. These tools can serve to augment clinical assessment and allow standardized evaluation from one patient to the next ( 3 ).

Differential Diagnosis

The differential diagnosis of personality disorder includes substance use disorder, personality change due to a general medical condition, neurocognitive disorder, and autism spectrum disorder, as well as several other mental health disorders. The presence of a substance use disorder may result in pathologically unempathic, impulsive behavior that may shatter close relationships. Obtaining a careful history of current or previous substance use is essential. Autism spectrum disorder may mimic schizoid personality disorder. However, patients with schizoid personality disorder demonstrate a complete lack of interest in close relationships, whereas patients with autism spectrum disorder frequently have close relationships with some friends, family members, or both. Impaired interpersonal functioning may occur during a time of notable crisis, such as job loss, foreclosure, death of a family member, or sudden decline in health. Also, patients presenting with, for instance, major depressive disorder or posttraumatic stress disorder may exhibit maladaptive personality traits that resolve with treatment of the underlying mental health disorder. Therefore, it is important to distinguish transient declines in interpersonal functioning related to stressors from a chronic, long-standing personality disorder.

A wide range of medical disorders may result in a change in personality. It is especially important to obtain a history of any falls, concussions, prolonged involvement in contact sports with the potential for brain trauma, motor vehicle accidents, strokes, severe illness resulting in delirium, or severe illness necessitating treatment in an intensive care unit. In a patient with a history of significant accident, illness, or injury, care must be taken to ensure that maladaptive personality traits were present and were causing clinically significant functional impairment before the accident, illness, or injury. In cases when premorbid traits and functioning cannot be determined, the most appropriate diagnosis is personality change due to a general medical condition.

Lack of empathy, apathy, social withdrawal, and impulsivity may all be seen in neurocognitive disorders or personality disorders. Personality disorders are themselves associated with subtle impairments across a range of cognitive domains, including executive function, memory, processing speed, and visuospatial abilities ( 4 ). Neuroticism is especially associated with increased cognitive decline ( 5 ). For these reasons, an evaluation of cognitive function is essential when assessing older patients with maladaptive personality traits.

Prevalence, Impact, and Comorbidity

Personality disorders are among the most common mental disorders, with a prevalence of 15% in the general adult population, similar to the prevalence in the older adult population ( 2 , 6 ). Obsessive-compulsive disorder (7.6%) and narcissistic personality disorder (3.9%) are the most common, whereas histrionic (0.7%) and dependent (0.26%) personality disorders are the least common ( 2 ). Older men are more likely than older women to demonstrate any personality disorder ( 2 ). However, paranoid, avoidant, and dependent personality disorders are more common in older women. In general, personality disorder prevalence declines with increasing age ( 2 ).

On average, patients with personality disorders demonstrate increased health care utilization but suffer from worse health care outcomes. Patients with personality disorders have increased risk of stroke and heart disease and increased mortality ( 7 ). Personality disorders are associated with increased risk of obesity, underweight, smoking, alcohol use disorder, diabetes, arthritis, and gastrointestinal disorders ( 7 ). Antisocial personality disorder has been found to be associated with increased risk of accidental injury, hepatitis C infection, and HIV infection ( 8 ). Time to treatment response is prolonged, and treatment response is decreased for older patients with comorbid mood and anxiety disorders ( 9 ). Moreover, patients have decreased functional status and quality of life, even after depression remission. Overall, older patients with personality disorders generally have increased suicide risk ( 10 ). Narcissistic personality disorder is likely a risk factor for suicide among depressed older adults.

In the general adult population, patients with borderline and antisocial personality disorder are at markedly increased risk of suicide attempt and suicide completion ( 8 , 11 ). The average age at suicide completion in patients with borderline personality disorder is in the 30s ( 11 ). Over the long term, nonsuicidal self-injury, suicide attempts, and unstable relationships in patients with bipolar disorder tend to decrease. However, affective symptoms of borderline personality disorder—dysphoria, feelings of emptiness, and anger—tend to be chronic ( 12 ). These are the symptoms of borderline personality disorder that clinicians commonly encounter in older adult patients. In antisocial personality disorder, homicides and accidents, as well as suicide completion, contribute to premature mortality ( 8 ). Arrests decline from a peak in the late teens ( 8 ). On average, antisocial personality disorder symptoms improve by the mid-30s ( 8 ). By older age, arrests of patients with antisocial personality disorder are typically for nonviolent crimes. However, patients with antisocial personality disorder generally continue to struggle with impaired interpersonal relationships and decreased occupational function in the long term ( 8 ).

The presence of a personality disorder may complicate rapport between patient and health care provider so that important problems are not addressed. This may be due to the patient’s failure to disclose concerns or to a lack of guideline-recommended care in time-limited visits when other problems may appear predominant, or when interpersonal conflict between a patient and provider may dominate the encounter to the detriment of the patient’s quality of care. Patients with personality disorders may also be less adherent to medical recommendations.

Patients with personality disorders are more likely to be absent from work and have lower productivity while at work. Across a range of interpersonal relationships, patients with personality disorders demonstrate impaired role functioning, with potentially devastating effects on their relationships with family, friends, and acquaintances. Personality disorders are frequently comorbid with mood, anxiety, and substance use disorders ( 2 ).

Treatment Strategies and Evidence

Data on treatment of personality disorders in the elderly are limited, but there have been important clinical advances in small studies. A study of dialectical behavioral therapy (DBT) in patients with depressive disorder and personality disorder showed positive results on improvement of depression. Thirty-four depressed adults over age 60 were randomized to treatment with medications only or medications plus group skill-based DBT plus a 30-minute weekly coaching session ( 13 ). Participants who received DBT were more likely to remit from depression ( 13 ). This study did not assess the effect of treatment on personality disorder as a primary outcome measure. In another study of 45 participants aged 55 or over, patients with a personality disorder and major depressive disorder were randomized to receive medication management only versus standard DBT in combination with medication management ( 13 ). Twenty of the 45 patients had obsessive-compulsive disorder, and an additional 10 had avoidant personality disorder ( 13 ). Over the course of treatment, both groups showed improvement in major depressive disorder symptoms and personality functioning ( 13 ). A total of 16 patients in both groups remitted from their personality disorders over the course of treatment ( 13 ). A small study of schema therapy has shown that this therapeutic option is promising. Eight patients with cluster C personality disorder were repeatedly assessed during a baseline phase of random length and then had schema-based therapy over the course of eight months. Authors found a high effect size, and seven patients remitted from their personality disorder ( 14 ). An earlier study with a heterogeneous patient population, including 10 patients with various personality disorders, also indicated beneficial effects of group schema therapy ( 15 ).

There are no medications for treating personality disorders in older adults that have been approved by the Food and Drug Administration, and no randomized controlled studies have assessed medications specifically for treating personality disorders in older adults. However, in practice, medications are commonly used for target symptoms such as impulsive aggression or affective instability, so it is useful to review evidence from the general adult population. Most trials of pharmacotherapy for personality disorders have been conducted for patients with borderline personality disorder. Among patients with borderline personality disorder, there is accumulating evidence that divalproex can reduce impulsive aggression, irritability, and the overall severity of borderline personality disorder ( 16 , 17 ). Topiramate has been found to decrease anxiety and interpersonal rejection sensitivity in patients with borderline personality disorder ( 16 , 18 ). The beneficial effects of topiramate were sustained in long-term open-label follow-up. There are suggestions that naltrexone may reduce self-harm and dissociation ( 16 , 19 ). Several second-generation antipsychotics have been found to reduce impulsive aggression, psychosis, and interpersonal rejection sensitivity in patients with borderline personality disorder ( 20 ). Olanzapine and aripiprazole are the best studied second-generation antipsychotics in this regard. Aripiprazole, but not olanzapine, is effective in reducing nonsuicidal self-injury in patients with borderline personality disorder ( 16 , 21 ). Small trials of omega-3 fatty acids for borderline personality disorder have shown positive effects: decreased aggression and parasuicidal behaviors, improved affect, and decreased stress reactivity ( 16 , 20 , 22 ). There are hints that antipsychotics are helpful for psychotic symptoms in schizotypal personality disorder, whereas guanfacine may attenuate cognitive deficits ( 16 , 23 , 24 ). Serotonergic agents are commonly used in avoidant personality disorder, as a comorbid social anxiety disorder is frequently present, but the impact of this approach on outcomes in avoidant personality disorder per se (rather than on outcomes in social anxiety disorder) has not been tested in clinical trials. For patients with social anxiety disorder and comorbid avoidant personality disorder, a trial of a selective serotonin reuptake inhibitor, monoamine oxidase inhibitor, gabapentin, or pregabalin is indicated ( 25 ). Information on the pharmacotherapy of other personality disorders is sparse. In all cases, care must be taken to use a consistent method to evaluate symptom severity, and the duration of an adequate trial must be defined to allow for clear decisions on whether a medication or intervention is clinically beneficial ( 16 ).

Questions and Controversy

Several aspects of diagnosing a personality disorder in older adults present unique challenges. It is often impossible to ascertain that observed personality traits and impaired functioning have been present since adolescence or early adulthood. Further, personality disorder traits may not be stable over an entire lifespan ( 13 ). Given the requirement that traits have their onset in adolescence or early adulthood, a patient who develops these traits by middle age and continues to exhibit them for decades will not meet the criteria for a DSM-5 personality disorder, even in the presence of significant functional impairment because of these traits ( 3 ). Several criteria for the diagnosis of personality disorders are contextually inappropriate for older adults ( 1 ). For instance, older patients with antisocial personality disorder may be frail and physically unable to get into fights or assault others (criterion 4). Some criteria mention detrimental effects on work performance; for instance, failure to sustain work consistently in patients with antisocial personality disorder or relentless devotion to work in patients with obsessive-compulsive disorder. There criteria are irrelevant to older adults who are retired, chronically unemployed, or disabled. Older adults may naturally have a smaller sphere of social support that is highly reliant on immediate family members because of the loss of friends and extended family over time. However, this entirely common state of being in older adults satisfies criterion 5 of schizoid personality disorder: “lacks close friends or confidants other than first-degree relatives.” Further research is needed to identify psychotherapies that are effective across a range of personality disorders in older individuals. For instance, mentalization-based therapy has been found to be effective for borderline personality disorder in the general population, but this has not been evaluated in older individuals. Trials of pharmacotherapy for personality disorders in older adults are entirely lacking. Research is needed to assess for the possible existence of a late-onset personality disorder phenotype.

Recommendations

With a certain pragmatic cynicism, practitioners often question the value of arriving at a personality disorder diagnosis, particularly given the challenges of making this diagnosis in older adults, perceived limitations in treatment options, and possible negative effects on insurance reimbursement. Furthermore, there is a tendency for maladaptive personality traits to be dismissed or ignored in older adults. However, a diagnosis of personality disorder has important clinical implications, prompting evaluation for likely comorbidities, negatively affecting prognosis, and requiring specialized treatment that is simply impossible in the absence of diagnosis. Several screening tools have been validated in older adults to aid in the diagnosis of a personality disorder. With their high prevalence; high symptom burden; and broad impacts on treatment outcome, mortality, and suicide risk, personality disorders cannot be ignored. There is emerging evidence that DBT can be effective in patients with a comorbid depressive disorder, and schema therapy also shows promise. Technological advances have created the opportunity for delivery of in-home virtual group therapy. There is increasing evidence that mood stabilizers and second-generation antipsychotics are effective at targeting certain features of personality disorders in the general population. As yet, however, there are no studies of pharmacotherapy in older adults.

Dr. Brudey reports no financial relationships with commercial interests.

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• Cited by None

• Personality disorder
• geriatric psychiatry
• obsessive-compulsive disorder

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A Comprehensive Literature Review of Borderline Personality Disorder: Unraveling Complexity From Diagnosis to Treatment

Sanskar mishra.

1 Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND

Alka Rawekar

2 Physiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND

Bhagyesh Sapkale

Borderline personality disorder (BPD) is a severe mental illness marked by unpredictable feelings, behaviors, and relationships. Symptoms like emotional instability, impulsivity, and poor social connections are the basis for diagnostic criteria. A noteworthy discovery highlights the clinical overlap between BPD and several psychotic disorders by arguing that BPD and psychotic symptoms raise the risk of psychopathology. According to neuroimaging evidence, structural and functional brain changes, notably in regions controlling affective regulation and impulse control, are seen in BPD patients. Adolf Stern, a psychoanalyst, used the word "borderline" in 1938 to describe patients who exhibited increased symptoms during therapy and displayed masochistic tendencies. Modern BPD research has highlighted the complexity of symptoms like boredom, a former diagnostic criterion associated with feelings of emptiness.

Though there are still unanswered problems regarding its precise, practical components, the treatment technique known as Schema therapy (ST) has shown promise in treating BPD. It's interesting to note that BPD displays complex relationships with other illnesses; for instance, some neurochemical pathways coincide with those in bulimia nervosa, pointing to a deeper level of interconnection. Concerning diagnosis, BPD's defining symptoms include, among others, the fear of abandonment, identity disruption, and recurrent suicidal conduct. The range of treatment options includes pharmacological interventions and psychotherapies like dialectical behavior therapy (DBT). Even though antidepressants like selective serotonin reuptake inhibitors (SSRIs) are routinely prescribed, research on their efficacy is ongoing, underlining the significance of thorough treatment planning. In conclusion, BPD continues to be a complex condition that calls for early detection, especially considering that it usually manifests in adolescence. While many patients report symptom relief, lingering problems still exist, emphasizing the value of comprehensive and personalized treatment strategies.

Introduction and background

A psychiatric disease known as borderline personality disorder (BPD) is characterized by unpredictable mood, conduct, and interpersonal interactions [ 1 ]. There is uncertainty about BPD's origin. Based on the symptoms, clinicians form a diagnosis. Emotional instability, worthlessness, insecurity, impulsivity, and deteriorated social interactions are symptoms. According to studies, 10% of BPD patients also had bipolar I disease, and 10% had bipolar II disorder. About 10% of individuals with bipolar I had the condition, and about 20% of individuals with bipolar II had it [ 2 ]. BPD is a long-term mental health disorder characterized by suicidal conduct, unstable mood and relationships, and extreme impulsivity [ 3 ]. Typically, BPD patients attempt suicide three times in their lifetimes, most frequently by overdose; non-suicidal self-injury (NSSI) is another self-harm activity prevalent in BPD [ 4 ]. The Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition's classification of BPD as an illness of the mind in 1980 brought about clinical and academic attention [ 5 ]. NSSI typically manifests as little wounds on the arms and wrists. NSSI, however, does not have a suicide motive; instead, BPD patients cut themselves compulsively to cope with uncomfortable inner states. Cutting is a way to release emotional stress, not a sign of a death wish [ 4 , 5 ].

The availability of specific efficient psychotherapies, the potential over-prescription of drugs with minimal benefits, and the danger of medically significant adverse effects make identifying BPD clinically relevant. BPD's three core symptom domains are impulsivity, affective dysregulation, and cognitive-perceptual symptoms (paranoia and dissociation). In Western nations, 0.4-3.9% of people suffer from a crippling psychiatric disease called borderline personality disorder (BPD) [ 6 ]. Regulatory bodies have not authorized any drugs to treat BPD. Despite this, up to 96% of BPD patients take at least one psychotropic drug [ 6 ]. Antipsychotics do not significantly affect mood instability, cognitive-perceptual signs and symptoms, or overall functioning [ 7 ]. They also had a minor to moderate impact on rage. The findings could not be used to evaluate individual antipsychotics because they were combined. People with borderline personality disorder are typically treated with psychotherapy [ 8 ]. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) model for personality disorders, high levels of disinhibition are a common feature of both borderline personality disorder and antisocial personality disorder; high levels of negative affectivity and elevated levels of antagonism are also associated with BPD and antisocial personality disorder, respectively [ 9 ]. BPD sufferers do engage in self-harming behavior [ 10 ]. Among adults, 2.7% have BPD. Addiction or substance use issues are experienced once in their lifetime by 78% of people with BPD [ 9 ]. Those with BPD who use drugs have increased levels of impulsivity and clinical instability. They exhibit more suicidal behavior, frequently leave treatment, and have shorter abstinence periods [ 11 ]. A unique therapeutic approach is necessary when borderline personality disorder and addiction are present.

Search methodology

The study aimed to conduct an exhaustive literature review on borderline personality disorder (BPD). The focus was placed on the disease's onset, diagnostic standards, signs, symptoms, treatment, and other aspects, focusing on its history, neurological foundations, and related comorbidities. Major databases like PubMed, PsycINFO, Google Scholar, Cochrane Library, and Web of Science were used. Searches included a variety of terms, including "borderline personality disorder" and "diagnosis,", as well as more specific terms like "neurological basis" and "adolescent onset". We set the study period between 1990 and 2022 to thoroughly synthesize historical and modern findings. The inclusion criteria were strict; only research focusing on BPD symptoms, treatments, historical background, neurological alterations, and comorbidities was considered. After careful removal of duplicates, non-English entries, opinion-based articles, and research with hazy procedures from an initial discovery of 1,500 articles, we ultimately selected 400 studies. The selected papers provide details about the authors, the study's goals, demographic information from the sample, and the key findings. However, there were certain restrictions. Due to database indexing limitations, not all pertinent papers may have been included, and there may be publication bias in favor of research with notable findings. Yet this exacting process resulted in a significant synthesis of BPD. The condensed information provided a more transparent comprehension of the complexity of BPD, illuminating various treatment options and pointing out areas that need further research. The Prisma flow diagram is shown in Figure ​ Figure1 1 .

PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Borderline personality disorder

A mental illness is marked by unpredictability in mood, behavior, and relationships. Uncertainty surrounds the origin of BPD. Symptoms are used to form a diagnosis. Emotional instability, worthlessness, insecurity, impulsivity, and deteriorated social interactions are symptoms [ 12 ]. The presence of both BPD and psychotic signs is an indication of a serious psychopath and a risk for adverse outcomes (such as suicidality), as there are more similarities than differences between the symptoms in those suffering from psychotic disorders and auditory verbal illusions, especially in BPD sufferers [ 13 ]. BPD patients have structural and functional brain changes, especially in brain areas related to impulse control and emotional and cognitive regulation [ 14 ]. Specialized psychotherapies have focused on beliefs concerning the causes and variables that maintain BPD, and they have published thorough protocols on how to treat BPD, use therapeutic methods, and manage the therapeutic alliance [ 15 ]. One of the most common DSM-5 illnesses is post-traumatic stress disorder (PTSD), with a lifetime prevalence of 10% [ 16 ].

Psychoanalyst Adolf Stern used the term "borderline" for the first time in 1938. The word was used to characterize a group of individuals whose problems became worse while they were receiving therapy, exhibiting a rigid mentality and masochistic behavior, suggesting an attempt to defend against any imagined changes in the outside world or within the person [ 17 ]. BPD discusses boredom reactivity and its relationship with emptiness. DSM previously linked boredom reactivity to BPD but later removed it [ 18 ]. Research has discovered that Schema therapy (ST) successfully treats BPD [ 19 ]. However, very little is known about how treatment works for people with BPD, mainly which specific ST components are effective or ineffective in their eyes. Adolescents with BPD do not always recover, even if they frequently shed certain BPD-related features with time. Any personality disorder with high levels of adolescent symptoms will negatively impact functioning over the course of the next ten to twenty years; these consequences are frequently more pronounced or persistent than those associated with disorders associated with Axis I [ 20 ]. A spectrum connection between borderline personality disorder and schizophrenia was implausible. Except for the periodic lapses in reality testing, borderline patients were intensely emotional and interpersonally needy [ 21 ]. Compared to women with borderline personality disorder (BPD) or bulimia nervosa/bulimia spectrum disorder (BN/BSD-BPD), women with BN/BSD-BPD showed significantly lower levels of serotonin and monoamine oxidase activity (HC). When compared to women with BN/BSD and HC, women with BN/BSD-BPD also showed higher levels of brain-derived neurotrophic factor, alterations in the methylation of the glucocorticoid receptor gene promoter (NR3C1), and dopamine receptor gene promoter methylation [ 22 ]. Both complex post-traumatic stress disorder (cPTSD) and perinatal BPD are linked to severe impairments in interpersonal functioning and an increased likelihood of psychopathology being passed down through generations [ 23 ].

Diagnosis of borderline personality disorder

BPD, a mental health disease that begins in early adulthood, is characterized by chronic instability in relationships, one's self-image, emotions, and impulsive conduct. At least five of the given nine signs must be present for a person to be diagnosed with the condition: ongoing empty feelings, intense or inappropriate anger, fear of abandonment, unstable interpersonal relationships, identity confusion, impulsivity, recurrent suicidal thoughts, emotional instability, and occasionally psychotic-like thinking or dissociation [ 24 ]. BPD covers a wide range of emotional and social difficulties. The dread of abandonment, unstable interpersonal connections that oscillate between idealization and devaluation, a shaky self-image, impulsive behaviors, and frequent suicidal thoughts are among its main symptoms. Rapid mood swings, emptiness, unrestrained wrath, and occasionally skewed perceptions or dissociation are additional symptoms that BPD sufferers may encounter [ 25 ]. These symptoms highlight the difficulties BPD sufferers have. Symptoms of BPD are shown in Table ​ Table1 1 .

BPD: borderline personality disorder

Symptoms of BPD

Treatment of borderline personality disorder

The most commonly given drugs for BPD are fluoxetine, selective serotonin reuptake inhibitors (SSRIs), and citalopram, despite a shortage of research to support their usage [ 26 ]. It was shown that the most common correlation between giving antidepressants to individuals with BPD is comorbidity for affective disorders [ 26 ]. Early childhood impacts on the development of BPD's psychopathology include parenthood-related issues such as dysfunctional parenting, parenting philosophies, and parenting psychopathology [ 27 ]. Staged therapy designs, additional treatments, and technology-based interventions could be beneficial in cases where developing cost-effective interventions is necessary when people are newly diagnosed or are awaiting full-package therapy (or both) or when a particular deficit needs to be addressed in the context of ongoing treatment [ 28 ]. Furthermore, considering the growing body of research indicating that BPD is a diagnosable disorder in teenagers, treatments aimed at younger demographics constitute an important and required step. Table ​ Table2 2 displays the treatments available for BPD.

DBT: dialectical behavior therapy; MBT: mentalization-based therapy; TFP: transference-focused psychotherapy; ST: Schema therapy

Psychotherapy, such as dialectical behavior therapy (DBT) for emotional regulation and relationship improvement and mentalization-based therapy (MBT) to understand one's own feelings as well as those of others, is the mainstay of treatment for BPD [ 29 ]. While Schema therapy targets dysfunctional life patterns, transference-focused psychotherapy (TFP) uses therapist-patient interaction to gain emotional insight [ 8 ]. Antipsychotic drugs control rage and impulsivity; mood stabilizers target mood swings; and antidepressants handle mood and irritability [ 8 ]. Hospitalization guarantees safety and intensive care in severe conditions. In group therapy, participants foster peer support and develop common coping mechanisms. Before beginning any treatment, it is essential to seek professional guidance. Borderline personality disorder (BPD) often manifests throughout adolescence; early identification and treatment are crucial [ 8 , 29 ]. While many BPD sufferers notice considerable improvements with time, it's essential to remember that a sizable percentage may continue to struggle with lingering symptoms as they age [ 30 ]. For prognosis, treatment planning, and patient counseling, being aware of these little differences is crucial from a professional standpoint. The analysis of the studies included is shown in Table ​ Table3 3 .

EMDR: eye movement desensitization and reprocessing; DBT: dialectical behaviour therapy; PTSD: post-traumatic stress disorder

Conclusions

Understanding and managing BPD remains one of the most intricate and challenging mental health issues. Due to its unpredictable moods, behaviors, and interpersonal ties, diagnosis and treatment must take a multidimensional approach. The interconnectedness of BPD with other diseases, like bipolar disorder and psychotic symptoms, emphasizes its complexity and necessitates a comprehensive approach to therapy. Although its origins are unclear, the focus on symptoms provides professionals with a clear path for diagnosis. Recent developments in psychotherapy approaches, particularly Schema therapy and dialectical behavior therapy (DBT), have given individuals suffering new hope by uncovering viable routes to recovery. Although experts frequently recommend some pharmacological therapies, ongoing controversy about their effectiveness emphasizes the need for further study in this field.

The high rate of self-harming behaviors and suicidal thoughts among BPD patients is an important cause for concern, underscoring the importance of early detection, particularly in younger groups. Early intervention can significantly change the trajectory of the condition, which is why the urgency is increased by the fact that BPD frequently manifests during adolescence. In addition, the historical context, from Stern's 1938 coining of the word “borderline” to the complexity of today's diagnosis and treatment of an illness, has drawn growing attention over the years. Significant obstacles still exist. A more complex knowledge of BPD is crucial as we go. To guarantee people afflicted by BPD receive the comprehensive support they require, ongoing research, interdisciplinary collaboration, and patient-centered care are essential.

The authors have declared that no competing interests exist.

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Personality disorder in older people: how common is it and what can be done.

Published online by Cambridge University Press:  02 January 2018

• eLetters (1)

There has been little systematic study of personality disorders in older people (65 years of age and above). However, with an ageing population worldwide we should expect to find increased numbers of people with Axis II disorders surviving into old age. We undertook a qualitative review of the recent literature concerning personality changes and disorders in older people, their prevalence and possible amelioration.

As the proportion of the population that survives to old age increases, we might expect to encounter more frequently in this group psychiatric conditions more commonly associated with early and middle adulthood. With this in mind, we have been interested in examining what is known about the prevalence and management of personality disorders among older people (65 years of age and above).

Personality and age

Although one's core personality is thought to remain stable over the adult years, modest variation may arise in terms of its expression with advancing age. For instance, an increase in obsessive–compulsive traits is common among older people and may reflect not so much a change in intrinsic personality as an adaptation of the person to failing powers or altered relationships and environments ( Reference Engels, Duijsens and Haringsma Engels et al , 2003 ). The neurological substrate of reduced adaptability has also been variously investigated in the context of cerebrovascular pathology ( Reference Stone, Townend and Kwan Stone et al , 2004 ) and falling levels of central neurotransmitters (e.g. dopamine; Reference Volkow, Gur and Wang Volkow et al , 1998 ).

Personality disorder ( Box 1 ) is a controversial concept but the diagnosis remains pertinent in older people provided that a suitable account of long-standing dysfunction can be established that pre-dates presentation. In simple terms, personality disorder may be construed as a long-standing pattern of maladaptive interpersonal behaviour ( Reference Kroessler Kroessler, 1990 ). So, although it might be considered very late for the condition to present in old age (perhaps marking the culmination of many unhappy events for the individual) there might at least be the advantage of a considerable longitudinal history and pattern of behaviour for the examiner to investigate at the time of assessment.

Box 1 Diagnostic categories of personality disorder

DSM–IV (American Psychiatric Association, 1994)

Cluster A: ‘eccentric’

• Schizotypal

Cluster B: ‘flamboyant’

• Antisocial

• Borderline

• Histrionic

• Narcissistic

Cluster C: ‘anxious’

• Dependent

• Obsessive–compulsive

ICD–10 ( World Health Organization, 1992 )

• Dissocial

• Emotionally unstable

• Anankastic

Box 2 Barriers to diagnosis

• Lack of co-informant

• Co-informant with little knowledge of patient's early life

• Unreliable patient and/or co-informant

• Cognitive impairment of patient and/or co-informant

• Co-informant's characteristics (e.g. shame, minimisation, embarrassment, guilt) affect their account

• Severe physical illness in patient

• Axis I and Axis II similarities, e.g. paranoid personality disorder v . paraphrenia; dissocial personality v . frontotemporal dementia

There are relatively few prevalence data concerning personality disorder in older people, yet ICD–10 asserts that such disorders are stable and enduring over time ( World Health Organization, 1992 : p. 200). Hence, by inference, personality disorder ‘should’ be seen among this stratum of the population. However, as age advances, certain ‘problem’ behaviours associated with personality disorder (e.g. impulsivity, aggression, promiscuity, fighting and law-breaking) might be expected to decline in frequency, while comorbid psychiatric disorders might enhance the expression of other dysfunctional traits: there is, for instance, a predominance of social withdrawal and major depressive and dysthymic disorders among older people ( Reference Devanand Devanand, 2002 ).

The prevalence of personality disorder among older people in the community has been estimated to be about 10% ( Box 1 ) ( Reference Abrams and Horowitz Abrams & Horowitz, 1996 ).

Among older in-patients, personality disorder has been described in 6% of those with organic mental disorders and 24% of those with major depressive disorder ( Reference Kunik, Mulsant and Rifai Kunik et al , 1994 ). In this sample, cluster C personality disorders (mainly the anxious and dependent types) were again more common. Patients with early-onset depression were more likely to exhibit personality dysfunction, mainly avoidant, dependent and ‘not otherwise specified’ ( Reference Kunik, Mulsant and Rifai Kunik et al , 1994 ; Reference Abrams and Horowitz Abrams & Horowitz, 1996 ). There is also some evidence that among older patients with major depressive disorder, personality disorder is associated with a recurrent pattern of (depressive) illness ( Reference Kunik, Mulsant and Rifai Kunik et al , 1994 ).

A further study, of 76 older people with dysthymia, found 31% (24) to have personality disorder. Of these, 17% (4) had obsessive–compulsive personality disorder, 12% (3) had avoidant personality disorder and 5% (1) had borderline personality disorder ( Reference Devanand, Turret and Moody Devanand et al , 2000 ).

As alluded to above, there is thought to be a reduction with age in certain dissocial behaviours and a possible decline in cluster B personality disorders ( Box 1 ). If true, such a decrease might be attributable to:

• a reduction in dramatic behaviour intrinsic to ageing

• age-related neurobiological changes that affect the manifestation of dissocial conduct

• increasing physical incapacity, reducing the ability to ‘act out’

• attrition (through death) of those who have died by suicide or from other causes connected with personality disorder (e.g. recklessness)

• omission from studies of older people with antisocial personality disorder who are in prison or forensic psychiatric hospitals ( Reference Fazel, Hope and O'Donnell Fazel et al , 2001 )

• a cohort effect, whereby older age groups derive from cohorts who had lower (pre-existing) levels of personality disorder than their younger comparators.

It is also possible that the natural history of the disorder is one of gradual improvement. Certainly, there is an anecdotal belief that certain personality disorders, for example borderline personality disorder, may ‘burn out’ with age. Indeed, the outcome of the latter is generally better than may be routinely acknowledged ( Reference Stone Stone, 1993 ). Two-thirds are clinically well at follow-up, although they may retain mild residual symptoms ( Reference Stone, Hurt and Stone Stone et al , 1987 ). One study found that only one-quarter of people with an initial diagnosis of borderline personality disorder retained this full diagnosis at long-term follow-up ( Reference Zanarini, Frankenburg and Hennen Zanarini, 2003 ). As the individual ages, it seems that impulsivity resolves first; next to improve is interpersonal functioning, and affective symptoms are the last to reduce or disappear.

Personality disorder among older prisoners in England and Wales has been studied by Reference Fazel, Hope and O'Donnell Fazel et al (2001) . The prevalence was 30% (in total), with avoidant and antisocial categories contributing most (8.3% each), followed by anankastic (7.9%), schizoid (6.4%) and paranoid (3.4%).

Personality disorder as a risk factor for abuse

If someone has a difficult personality, does this place them at increased risk as they become older and perhaps infirm? Of the potential risk factors for elder abuse identified by the House of Commons Health Committee (2004) identified, social isolation and a poor relationship with a carer might reflect personality difficulties; others, however, relate more to the perpetrator than the victim, for example dependence of the abuser on the person they abuse and a history of mental health problems, personality disorder, or drug and alcohol problems in the abuser. Although the public perception might be that older people are at greater risk of abuse in residential and nursing care, over two-thirds of elder abuse happens in the victims' own homes ( Fig. 1 ).

Fig. 1 Place of residence of people subjected to elder abuse in the UK ( House of Commons Health Committee, 2004 ).

Older people with anxious and dependent personality disorders may be particularly prone to abuse ( Reference Kurrle, Sadler and Cameron Kurrle et al , 1991 ), as are people undergoing organic personality change ( Reference Hansberry, Chen and Gorbien Hansberry et al , 2005 ). This may be due to their disinhibition, inability to communicate and/or lack of decisional capacity.

Comorbidity associated with personality disorder

Personality disorder is often associated with an Axis I psychiatric disorder, and this may compound problems for the potential patient and their carer(s). The link between depression and personality disorder seems well established ( Reference Devanand Devanand, 2002 ). Also, many patients with late-onset schizophrenia have never married, live alone and may have exhibited abnormal premorbid personality traits ( Reference Fuchs Fuchs, 1999 ).

Affective disorder

Consistent data suggest that there is a strong relationship between personality disorder and depression. A case example is described in Box 3 . The rate of personality disorder with a comorbid diagnosis of major depression was 24% in one study ( Reference Kunik, Mulsant and Rifai Kunik et al , 1994 ). In older people with personality disorder, there is a high rate (73%) of adult-onset rather than late-onset (geriatric) depression (45%) ( Reference Camus, de Mendonca Lima and Gaillard Camus et al , 1997 ).

Box 3 Personality disorder and depression: a case example

A 69-year-old widow was referred for depressive symptoms following social stressors (a son had emigrated). She had shown little response to antidepressants prescribed by her general practitioner.

It transpired that she had withheld information regarding contact with psychiatric services in early adult life for recurrent self-harm (lacerations to her wrists).

Placing her recent stressors in the context of her longer-term problems helped her to adjust (she had experienced separations before and survived).

Her antidepressant medication was adjusted and she received follow-up with the mental health team. Her depression responded well and she returned to independent living.

In a sample of older patients with dysthymic disorder, a personality disorder co-occurred in a minority and mainly comprised the obsessive–compulsive and avoidant subtypes ( Reference Devanand, Turret and Moody Devanand et al , 2000 ).

Anxiety disorder

Anxiety is a frequent concomitant of depression. Individuals with cluster C personality disorders seem more prone to developing anxiety disorder, phobias and acute stress disorder. Reference Sanderson, Wetzler and Beck Sanderson et al (1994) examined personality disorder in 347 patients with anxiety disorder and found that the most common were avoidant (13%), obsessive–compulsive (11%) and dependent (8%) subtypes.

Somatisation disorder

Two-thirds of older people with depression have hypochondriacal ideas ( De Alarcon, 1964 ); the main preoccupation being their bowels. In 30% of these patients, hypochondriacal ideas (somatic concern or hypochondria) precede depressive symptomatology.

Substance misuse

Certain personality disorders, especially those in clusters B and C, are more likely to involve problem alcohol use. In a study by Reference Speer and Bates Speer & Bates (1992) , it was found that older people are more likely to have the ‘triple diagnosis’ of personality disorder, alcohol dependence and depression.

Diogenes syndrome

Some people consider Diogenes syndrome to be an end stage of personality disorder. It refers to extreme self-neglect, unaccompanied by a medical or psychiatric condition sufficient to account for the condition. It can be seen as the response of someone with a particular personality type to old age and loneliness. It might also be a reaction to stress in older people with certain personality characteristics such as the schizotypal or anankastic ( Reference Rosenthal, Stelian and Wagner Rosenthal et al , 1999 ).

Of course, personality changes occur in organic disorders even if they are not classified as personality disorder. Changes such as apathy and dysphoria have been described in Alzheimer's disease ( Reference Landes, Sperry and Strauss Landes et al , 2005 ). Frontotemporal dementia is characterised by personality changes such as lack of insight, apathy and disinhibition. Not all individuals experience such change, but in those that do three patterns have been reported: change at the onset of dementia; ongoing change with disease progression; and change into disturbed behaviour ( Reference Petry, Cummins and Hill Petry et al , 1989 ). Carers often describe personality changes such as becoming ‘out of touch’, reliant on others, childish, irritable, unreasonable, unhappy, cold and cruel ( Reference Wattis, Butler and Pitt Wattis, 1998 ). Some of these features may be attributable to organic changes, whereas others are a reaction to dementia. It is also possible that the dementing process ‘releases’ underlying behavioural propensities that the patient may have been better able to control when well.

Management of personality disorder

There is a very sparse literature on the management of personality disorder in older people: the basic principles are listed in Box 4 . However, as mentioned earlier, personality disorder is commonly accompanied by an Axis I disorder, and judicious treatment of the latter may ameliorate certain aspects of the personality disturbance.

Box 4 Principles of treating personality disorder

• Form a therapeutic alliance

• Treat any comorbid Axis I disorder

• Adopt a consistent approach

• Use supportive cognitive psychotherapy

• Establish good links with other professionals

• Involve significant others where possible

Role of medication in treatment

Medications are often used to treat the functional illnesses comorbid with personality disorders.

The mainstays of pharmacological treatment of depressive disorders are obviously the anti-depressants. However, because of the frailty and physiological changes that occur with age, they are often started at low doses and increased slowly. The most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs), owing to their safer side-effect profile and less frequent interactions with other medications. Reference Kunik, Mulsant and Rifai Kunik et al (1994) reported that older in-patients both with and without personality disorder who had major depression benefitted equally from treatment, primarily anti-depressant medication or electroconvulsive therapy (ECT). Conversely, Reference Thompson, Gallagher and Breckenridge Thompson et al (1987) found that concomitant personality disorder in older patients with major depression decreased the likelihood of response to psychotherapy.

Low-dose antipsychotic drugs are mainly used to control agitation and psychotic symptoms ( Reference Bouman and Pinner Bouman & Pinner, 2002 ). Their appropriate use in older people has become an area of increasing debate: typical antipsychotics are generally more likely to induce extrapyramidal side-effects, but there are concerns over the safety of the atypicals in this age group ( Reference Herrmann and Lanctot Herrmann & Lanctot, 2006 ). The use of minimal effective doses seems vital here (as elsewhere in medicine).

Role of psychotherapy in treatment

Some expressions of troublesome personality traits will resolve with treatment of an associated or underlying functional disorder. However, when a patient has persistent or residual symptoms of personality disorder, a consistent approach from an experienced therapist may be of benefit.

As with younger patients with personality disorder, forming a therapeutic alliance can be difficult. Supportive, dynamic and cognitive approaches may be applicable, depending on the presenting complaint. It is important to have a consistent approach, with firm boundaries and good communication between the professionals involved. It is also important to involve the carers and to modify (if appropriate and possible) their reactions to untoward behaviour ( Reference Davison Davison, 2002 ).

Research suggests that the current generation of older adults are positively inclined to believe that talking therapy can help most people with depression and that they prefer psychological therapies to medication ( Reference Rokke and Scogin Rokke & Scogin, 1995 ). So, although older people may be initially less inclined to discuss their psychological issues, they appear not to be resistant to the idea of psychological intervention.

Nevertheless, the application of the psychotherapies has been slow to develop for this population, mainly because of ageism, negative stereotypes about the treatability of older people and a perceived lack of psychotherapeutic theories for later life ( Reference Hepple Hepple, 2004 ). The predominance of organic or biological models of old age may have biased the field towards ‘brain-based’ rather than ‘psyche-based’ explanations for illnesses in old age.

Cognitive–behavioural therapy

There is some evidence to suggest that adapted cognitive–behavioural therapy (CBT) is effective in addressing negative thoughts, identifying the dysfunctional cycles that can arise and intervening in unhelpful thinking patterns of older people ( Reference Thompson, Gallagher and Breckenridge Thompson et al , 1987 ). In a recent article in this journal on the use of CBT with older people, Reference Evans Evans (2007) suggested how it might be modified to accommodate the degree of cognitive change and sensory and physical impairment encountered among such patients. Reference Barrowclough, King and Colville Barrowclough et al (2001) demonstrated the effectiveness of CBT v . supportive counselling for anxiety symptoms.

In old age, people often face great challenges related to disability and loss – their social roles diminish and vanish, partners and friends die. These can precipitate lowered self-esteem and depression. Again, antecedent cluster C personality traits might constitute predisposing factors.

Cognitive analytic therapy

Cognitive analytic therapy (CAT) may help patients to acknowledge some of these issues and work on them:

‘Personality and relationships are not adequately described in terms of objects, conflicts or assumptions. They are sustained through an ongoing conversation within ourselves and with others – a conversation with roots in the past and pointing to the future. In their conversation with their patients, psychotherapists become important participants in this conversation and CAT, I believe, fosters the particular skills needed to find the words and other signs that patients need’ ( Reference Ryle Ryle, 2000 ).

Cognitive analytic therapy has been applied to late-life problems of patients with narcissism, borderline personality traits and post-traumatic syndromes ( Reference Hepple and Sutton Hepple & Sutton, 2004 ).

Psychodynamic therapy

Psychodynamic therapy is at least as effective as CBT in dealing with depression in older people ( Reference Thompson, Gallagher and Breckenridge Thompson et al , 1987 ) but the patient's age can affect the nature of the transference and countertransference. In most cases, one might anticipate that the patient will be older – perhaps by a great deal – than the therapist, and this may be worth considering at the outset, during patient allocation and supervision.

Dialectical behavioural therapy

Older people with personality disorder who become depressed have been shown to be less responsive to depression-specific therapies ( Reference Robins Robins, 2003 ). In such cases, it appears that dialectical behavioural therapy may show promise ( Reference Lynch Lynch, 2000 ). An adaptation of behavioural therapy, dialectical behavioural therapy aims to promote change in emotional ‘dysregulation’ ( Reference Robins Robins, 2003 ). Lynch found that it reduced interpersonal stress, hopelessness, avoidant, detached and emotional coping strategies, and also reduced dependency on, and desire to please, others.

Supportive psychotherapy

Supportive psychotherapy may be helpful for individuals with personality disorders who manifest low self-esteem and low self-confidence; it may also assist them in problem-solving and reducing the risk of future relapses or deterioration ( Reference Bloch and Bloch Bloch, 1979 ). Psychodynamically oriented supportive therapy may help people to strengthen their ‘ego function’ and promote a better adaptation to reality ( Reference Rockland Rockland, 1989 ). Personality changes often occur in dementia, and supportive psychotherapy may help affected patients and also provide some support for their carers ( Reference Junaid and Hegde Junaid & Hegde, 2007 ).

Family therapy

Likewise, family therapy may assist the families of people with dementia accompanied by personality change; it may be especially useful when counselling relatives before the diagnosis is revealed ( Reference Qualls Qualls, 2000 ). It can also inform awareness of family dynamics that are affecting the patient ( Reference Hepple Hepple, 2004 ).

Nidotherapy

Among younger people, there is growing evidence that nidotherapy may help to achieve a better fit, within the community, for people with personality disorders. It comprises a systematic adjustment of the environment to suit the needs of the individual ( Reference Tyrer and Bajaj Tyrer & Bajaj, 2005 ). The principles of nidotherapy might be applied to an older population to facilitate better coping skills and social functioning by manipulating their physical and social environment. The most obvious way of doing this is to offer patients access to residential care.

Conclusions

The literature concerning personality disorder among older people is currently quite sparse. This might be because personality disorders themselves have been rather contentious and, traditionally, old age psychiatry services have tended to focus on the management of dementia and the major Axis I disorders. However, it is likely that a greater number of patients with persistent Axis II disorders will survive into old age. Now would be a good time for psychiatric researchers to investigate the complex needs and issues associated with ageing among this group of people.

Declaration of interest

a as age advances, impulsivity, aggression and promiscuity decrease

b among older people, antisocial and borderline personality traits become more common

c cluster A personality disorders are most prevalent among older people

d dementing illnesses always precipitate changes in personality

e among older people, trial of medication is always of help for personality disorder.

a depression

b metachromatic leukodystrophy

c anorexia nervosa

d schizophrenia

a medications may not be useful in treating comorbid functional illnesses

b low-dose antipsychotics may help control disturbed behaviour

c older people believe that psychotherapy will not be useful for them

d psychotherapies have not been very useful

e ECT is a first-line treatment.

a parenting therapy

b cognitive analytic therapy

c counselling

d homoeopathy

e aromatherapy.

a treat associated Axis I disorders

b support the patient only – exclude the carer(s)

c always try medication

d never use a psychotherapy

e never investigate underlying physical illnesses.

MCQ answers

Fig. 1 Place of residence of people subjected to elder abuse in the UK (House of Commons Health Committee, 2004).

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• Volume 14, Issue 1
• Aparna Mordekar and Sean A. Spence
• DOI: https://doi.org/10.1192/apt.bp.107.003897

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A Life Span Perspective on Borderline Personality Disorder

• Personality Disorders (K Bertsch, Section Editor)
• Open access
• Published: 04 June 2019
• Volume 21 , article number  51 , ( 2019 )

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• Arjan C. Videler 1 , 2 , 3 ,
• Joost Hutsebaut 4 ,
• Julie E. M. Schulkens 5 ,
• Sjacko Sobczak 5 &
• Sebastiaan P. J. van Alphen 6 , 7 , 5  

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Purpose of Review

To provide an update of a life span perspective on borderline personality disorder (BPD). We address the life span course of BPD, and discuss possible implications for assessment, treatment, and research.

Recent Findings

BPD first manifests itself in adolescence and can be distinguished reliably from normal adolescent development. The course of BPD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent remission and relapse. Dimensional models of BPD appear more age neutral and more useful across the entire life span. There is a need for age-specific interventions across the life span.

BPD symptoms and impairments tend to wax and wane from adolescence up to old age, and presentation depends on contextual factors. Our understanding of the onset and early course of BPD is growing, but knowledge of BPD in late life is limited. Although the categorical criteria of DSM allow for reliable diagnosis of BPD in adolescence, dimensional models appear both more age neutral, and useful up to late life. To account for the fluctuating expression of BPD, and to guide development and selection of treatment across the life span, a clinical staging model for BPD holds promise.

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Introduction

The term borderline was first coined by Adolph Stern in 1938 when he identified a “border line group of patients” who “fit frankly neither into the psychotic nor into the psychoneurotic group, and are extremely difficult to handle by any psychotherapeutic method” [ 1 ]. The acceptance of borderline personality disorder (BPD) as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3rd edition in 1980 [ 2 ] has stimulated both clinical and scientific attention. BPD is characterized by impulsivity, self-harm, suicidality, and emotional and interpersonal instability. DSM-5 [ 3 ], like DSM-IV [ 4 ], allows diagnosing BPD under the age of 18, if the symptoms are pervasive, persistent, not limited to a particular developmental stage or another mental disorder, and if the symptoms have been present for at least 1 year.

The categorical DSM concept of BPD, and of personality disorders in general, has been criticized because of its heterogeneity, diagnostic overlap with other disorders, arbitrary threshold, low reliability, and poor empirical base [ 5 ]. Factor analytic studies found support for one general factor of personality pathology underlying the nine criteria of BPD [ 6 , 7 •]. Moreover, BPD presents with many comorbid disorders [ 8 ]. Because of these limitations, a growing number of studies focuses on dimensional models of personality disorders, such as the Alternative Model of Personality Disorders (AMPD) in the DSM-5 and the new personality disorder concept of the International Classifications of Diseases 11th Edition (ICD-11) [ 9 ]. Both models combine a severity dimension of personality pathology and a description of five personality trait domains. In the DSM-5 AMPD, BPD is defined by negative affectivity, disinhibition and psychoticism, and several studies have indicated general support for these traits proposed for BPD [ 10 , 11 , 12 ]. Interestingly, ICD-11 does not retain any specific personality type with the exception of an optional specifier for “borderline pattern”, operationalized as requiring at least five out of nine criteria adapted from the DSM-5 criteria for BPD [ 9 ].

Until around 1990, therapeutic nihilism prevailed concerning the treatment options of BPD [ 13 ]. Since then, beneficial effects have been demonstrated for four comprehensive treatments: dialectical behavior therapy (DBT), mentalization-based treatment (MBT), transference-focused psychotherapy (TFP), and schema therapy [ 14 , 15 ]. However, treatment studies have mainly been conducted in adults between the ages of 25 and 40, and effects remain modest and unstable at follow-up [ 14 , 15 ].

Recently, a life span perspective on BPD has been introduced, stressing a lifelong vulnerability of impairments in personality functioning, including poor mentalizing and impaired social cognition, along with persisting maladaptive traits like impulsivity, emotional lability, and separation insecurity [ 16 •]. Traits and impairments are supposed to underpin the phenomenological presentation, which may wax and wane throughout the life span, depending on the complex and changing nature-nurture interactions from early childhood onwards [ 16 •].

This review provides an update of recent studies and viewpoints on a life span perspective on BPD, and discusses possible implications for assessment, treatment, and research. A systematic literature search was conducted for articles published between January 2014 and January 2019 using the MEDLINE and PsycINFO databases. The keyword “Borderline Personality Disorder” combined with “life span” or its synonyms (“clinical course” and “course”) yielded 145 articles. We included 33 relevant articles (clinical trials or reviews) on life span perspective, risk factors, assessment, treatment, and comorbidity of BPD. We excluded articles that did not contribute to a life span perspective or did not primarily investigate BPD, were case reports, or were written in languages other than English.

Waxing and Waning Course of BPD from Childhood to Old Age

Childhood and adolescence.

Until the past decade, the vast majority of our knowledge of BPD concerned diagnosis and treatment of female patients in early adulthood. Since then, BPD has also been studied more extensively in adolescents. This research points out that BPD typically first manifests itself in adolescence, and that adolescent BPD symptoms can be distinguished reliably from normative adolescent development [ 17 ]. Moreover, adolescence can be considered a particular sensitive period for BPD pathology to emerge [ 7 •]. Two large longitudinal studies into the trajectory of BPD from childhood into young adulthood have shown that BPD pathology has its onset in the beginning of adolescence [ 18 , 19 ]. Over 30% of adult BPD patients reported retrospectively that the onset of self-injurious behavior was before the age of 13, while in another 30%, this behavior started between the ages of 13 and 17 [ 20 ]. From childhood to late adolescence, vulnerable children destabilize because of a wide range of risk factors [ 21 ]. These include the following: low social economic status, stressful life events, family adversity, maternal psychopathology, cold, hostile or harsh parenting, exposure to physical or sexual abuse or neglect, low IQ, high levels of negative affectivity and impulsivity, and both internalizing (depression, anxiety, dissociation) and externalizing (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, substance use) psychopathology in childhood [ 21 ]. These risk factors predict not only BPD, but a wide range of mental disorders. Prognostic factors that are specifically associated with a BPD development in children have not yet been identified [ 7 •, 21 ].

In adolescence, those individuals who do develop BPD can reliably be distinguished from those with a healthy development [ 22 , 23 ]. Impulsivity, identity issues and affective instability diminish in the course of adolescence in healthy youngsters, whereas these symptoms increase over time in BPD adolescents [ 23 , 24 , 25 ]. The differentiation between healthy development and BPD becomes more pronounced throughout adolescence [ 26 ].

Several studies have found prevalence rates of BPD in adolescents that are similar to those in adult populations, 1–3% in community-dwelling samples, 33–49% in clinical samples and 11% in outpatient samples [ 27 , 28 , 29 ]. This growing empirical evidence supports that DSM-5, ICD-11, and several national treatment guidelines allow the diagnosis of BPD in adolescence [ 30 , 31 ].

In sum, BPD first emerges in adolescence and symptoms mainly include impulsive behaviors and affective instability.

The course of BPD from adolescence to adulthood is characterized by a symptomatic switch from predominantly symptoms of affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent periods of remission and relapse of the full categorical BPD diagnosis, i.e., meeting the threshold of at least five out of nine DSM-criteria for BPD [ 16 •, 32 , 33 ]. Longitudinal studies show a general decrease of full BPD diagnoses from young to middle adulthood [ 34 , 35 ]. However, remission of the categorical BPD diagnosis is commonly followed by relapse, and almost half of BPD patients never recover fully, both socially and vocationally [ 35 , 36 ]. The course of core features of BPD, as assessed with retrospective questionnaires, persists throughout adulthood, such as affective symptoms (chronic dysphoria, anger, and feelings of emptiness), and interpersonal symptoms related to fears of abandonment, whereas impulsivity decreases during adulthood [ 35 , 36 , 37 ]. A recent cross-sectional e-diary study in everyday life showed higher affective instability prospectively between patients with BPD and healthy controls, ranging from 14 to 53 years of age, and also showed that affective instability declined with greater age in BPD [ 38 ]. Generally, the behavioral symptoms of personality disorders are less stable than the personality traits associated with BPD over time [ 39 , 40 ••]. Although self-injurious and suicidal behavior decreases, risk of suicide remains as high as 10% over a 27-year course [ 37 , 41 ]. Symptoms of BPD wax and wane over time, and the acute symptoms (e.g., suicidality, self-harm) change more rapidly and more readily than the temperamental symptoms (e.g., dysphoria, feelings of emptiness, and fear of abandonment) [ 40 ••].

BPD in young adulthood predicts a host of negative outcomes across the life span, including mood, anxiety, eating and substance use disorders, increased risk for physical illnesses and medical care, reduced quality of life, and reduced life expectancy [ 39 , 42 , 43 , 44 , 45 ]. As a consequence, many BPD patients never manage to fully participate in society [ 34 , 46 ].

Research on predictors of outcome of BPD, based upon the naturalistic course from adolescence into middle adulthood, has identified both positive and negative prognostic factors [ 40 ••, 46 ]. Predictors of good outcomes seem to be related mostly to personal capacity and competence, such as having a higher IQ, prior good full-time vocational functioning, higher levels of extraversion, higher levels of agreeableness, and lower levels of neuroticism. Predictors of poor outcomes are related to greater severity and chronicity of the disorder, higher degrees of comorbidity, and a history of childhood adversity. Non-recovered patients, which make up about 40%, experience higher rates of vocational impairment, disability, physical morbidity, and mortality than recovered patients [ 46 ].

Most longitudinal studies of BPD have not included people over the age of 50; because of this, our understanding of the course of BPD into late life is limited [ 16 •]. Cross-sectional studies suggest a further decline in the prevalence of BPD from middle adulthood to old age [ 47 , 48 ••]. The only ongoing longitudinal study into the prevalence and impact of personality pathology in later life, the SPAN study (St. Louis Personality and Aging Network), included patients between the ages of 55 and 64 and found a prevalence rate for BPD of 0.4%, and 0.6% if people with one criterion short for the full DSM BPD-diagnosis were included [ 49 ]. Different explanations can be pointed out for this decline in the prevalence of BPD. BPD patients, especially those that do not recover, are at elevated risk of premature death, due to suicide or other causes [ 50 ], related to an unhealthy and sometimes reckless lifestyle [ 51 ]. Furthermore, there are age differences in the expression of BPD symptoms. In a study among 1447 patients, aged 15–82 years, a significant decline was found in the externalizing aspects of BPD symptoms to the age of 50, such as impulsivity, rule breaking, and emotional turmoil, whereas abandonment fears, selfishness, lack of empathy, and manipulation remained the same [ 52 ]. In the SPAN study, three symptoms of BPD predicted interpersonal stressful life events: unstable interpersonal relationships, impulsivity, and chronic feelings of emptiness [ 53 ]. Interestingly, although impulsivity decreased with age in BPD, it continued to result in these negative consequences. BPD has also been found to predict arthritis and heart disease, in which obesity accounts for some of the variance in this relationship [ 44 , 54 ].

Recent large-scale IRT analyses on data of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) among more than 34,000 community-dwelling people, aged between 19 and 90 years, examined age differences in the likelihood of endorsing DSM-symptoms of BPD, when equating for levels of BPD symptom severity [ 48 ••]. Older people were consistently less likely to report suicidal/self-harm behavior than younger respondents and unstable/intense interpersonal relationships appeared to discriminate BPD severity better in the youngest age group compared to the oldest age group, with equivalent levels of BPD severity. It was further found that the nine DSM BPD-criteria provide substantially less information (14.7%) in older than in younger adults. Overall, these findings indicate substantial age-related differences in BPD symptom expression.

Case studies and clinical experience suggest that features of BPD can be exacerbated in old age due to contextual changes, even causing a growing prevalence of BPD in residential care and psychiatric facilities for the elderly [ 55 , 56 , 57 , 58 ]. Poor interpersonal functioning has caused many old BPD patients to be estranged from their family and former friends, and when they become dependent for care, this might re-trigger insecure attachment style issues and fears of abandonment [ 55 ]. BPD symptoms, together with trait neuroticism, appeared unique predictors of greater suicidal ideation in older adults, over other personality disorders and normal-range personality traits [ 59 ].

In an international Delphi study, experts in personality disorders in older adults reached consensus on the concept of “late-onset personality disorder”: a personality disorder that presents for the first time in old age as life events contribute to the expression of late-onset PD, with the major ones being death of a spouse or partner and transition to a nursing home or assisted-living facility [ 60 ]. This concept of a personality disorder emerging in late life is consistent with the ICD-11; while ICD-10 states that personality disorders tend to be stable over time, the ICD-11 guideline explicitly states that personality disorders are only “relatively” stable after young adulthood, and may change such that a person with a personality disorder in young adulthood no longer meets full criteria by middle age [ 9 , 61 ]. In some cases, a person who earlier did not have a diagnosable personality disorder, may develop one later in life. Sometimes, emergence of personality disorder in older adults may be related to the loss of social supports that had previously helped to compensate for personality disturbance. Triggers for late-onset BPD could be the loss of loved-ones, which might retrigger fears of abandonment.

In sum, a life span perspective on BPD could have important implications. Instead of being a fixed set of BPD symptoms, that is invariant throughout the life span, BPD features are dynamic in nature and their expression depends on contextual and developmental factors from childhood up to old age [ 56 ]. Most BPD patients demonstrate a waxing and waning profile of impairment throughout adult life with periods of remission and relapse, while some show stable remission [ 40 ••]. This fluctuating nature of BPD should have major impact on our assessment and treatment of BPD throughout the life span.

Assessment Implications of a Life Span Perspective

A life span perspective has two major implications for assessment of BPD. First, as the current categorical BPD diagnosis has appeared to be not age-neutral, especially in old age because of the changing expression of BPD symptoms [ 48 ••], it could be advocated to develop age-specific assessment instruments, or instruments that are age-neutral. For instance, an age-specific BPD screening instrument could be developed for the detection of BPD in older adults. The conceptualization of BPD in the AMPD in DSM-5, with levels of personality functioning (criterion A) and maladaptive trait dimensions (criterion B), has been studied for its age-neutrality in community-dwelling older adults, aged 61 and over [ 62 ]. The Short Form of the Severity Indices of Personality Problems (SIPP-SF), a questionnaire which can be used to assess criterion A, was found to be relatively age-neutral, as only 6% of the items performed differently for younger and older adults [ 62 ]. Of the Personality Inventory for DSM-5 (PID-5), which is designed to assess criterion B, only 16% of the 25 PID-5 facet-level scales showed potential age bias [ 63 ]. The brief version of this instrument, the PID-5-BF, appeared to show more age bias, as 25% of the five trait dimensions functioned differently in older adults [ 62 ]. Overall, these findings indicate that the AMPD functions similarly in older and younger adults, and is to be preferred over the current categorical model. Especially criterion A seems to be more age-neutral than criterion B.

The second implication of a life span perspective on BPD would be to develop a model that accounts for the development and possibly chronic course of BPD across the life span. Therefore, some authors have suggested a clinical staging model for BPD [ 56 , 64 ••]. Staging models of diseases originated in oncology and have been developed for mental disorders, for instance for psychosis [ 65 ]. The first clinical staging model for BPD was proposed for guiding early intervention in adolescence with BPD and comorbid mood disorders [ 64 ••], and was recently elaborated to assess the severity of BPD impairment throughout the life span [ 56 ]. Clinical staging offers a description of the progression of a disorder along a continuum of disorder progression, in which progression is typically specified into five stages, from a pre-morbid stage to an end or chronic stage [ 66 ]. Clinical staging is useful for personalized selection of appropriate interventions that match with the stage of disease an individual is in. Although a typical staging profile of BPD starts in a premorbid stage in childhood and develops into a subclinical stage in early adolescence and to a first episode of full BPD in middle or late adolescence, followed by remission and relapse from middle to late adulthood, other trajectories are possible. For example, in the case of late onset BPD, people might live for many decades in a subclinical stage, and only develop significant problems, and meet full BPD criteria later in life. Another stage trajectory might be that BPD wanes into partial remission in middle adulthood, because of a relationship with a stable spouse, but re-emerges in old age, due to the destabilizing effects of bereavement, or physical decline and admittance to a nursing home. Clinical staging might shift attention towards the degree in which borderline impairment has progressed and its impact upon age-specific developmental tasks across the life span [ 56 ]. Adopting a clinical staging model across the life span could be helpful to design interventions tailored to the stage of BPD.

Treatment Implications of a Life Span Perspective

As said, most of our knowledge of psychotherapeutic treatment of BPD comes from studies conducted in adults between the ages of 25 and 40 years, and these treatment models are focused on the acute episodes of the disorder. Typically, specialized treatments are offered rather late in the course of BPD, tend to be costly and lengthy, and available only to a subgroup of BPD patients who do seek help and manage to attend to the treatment setting [ 67 ]. Furthermore, as most existing treatments for BPD focus largely on the acute symptoms of self-harm and impulsivity, it might be fruitful to develop interventions that target underlying impairments, such as the affective symptoms, and improve social and vocational functioning, as they have been associated with recovery [ 40 ••, 46 ].

A life span perspective, adopting a clinical staging model, could be especially helpful to design interventions tailored to the stage of BPD. The earliest intervention is prevention of the onset of BPD by broad prevention programs. An example is preventing the transgenerational transmission of BPD, like mentalization-based treatment for parents (MBT-P) [ 68 ]. Early treatment programs target adolescents with emerging signs of BPD, such as Helping Young People Early-Cognitive Analytic Therapy (HYPE-CAT) [ 69 ]. Specific treatments have been developed for adolescents, such as DBT for adolescents (DBT-A) [ 70 ], and MBT for adolescents (MBT-A) [ 71 ]. Early intervention programs might also be developed for people with subthreshold BPD in late adulthood to prevent emerging late onset BPD, and for older adults with a first episode of acute BPD. Such treatment programs could focus on helping the older patient to adapt to age-specific stressors, like the death of a spouse or coping with becoming dependent for care. Adaptations of standard treatment programs, like MBT, DBT, TFP, and schema therapy, are needed for BPD in late life, and the first trial of schema therapy for BPD in older adults is currently being conducted [ 72 ]. Finally, specific treatment programs are needed for the frail and “old-old” BPD patients, which could be focused on staff understanding and behavioral management in care settings.

Research into the efficacy and tolerability of symptom-based pharmacotherapy for BPD [ 73 , 74 ] consists of relatively few trials, and is based on findings in adults up to 50 years of age, and the quality of these studies is generally low [ 74 ]. There is a lack of research on pharmacotherapy for BPD in adolescence and in older adults. Especially in older adults, polypharmacy and changing pharmacodynamics and pharmacokinetics are complicating factors in pharmacotherapy in BPD, which can lead to side effects and interactions [ 75 ].

Implications for Research

A life span perspective on BPD also helps defining new research objectives. One such goal would be to stop examining distal risk factors that are indicative for later general psychopathology and shed light on which precursors in childhood and adolescence are specific for BPD [ 7 •], and what personal and contextual characteristics determine a ‘high-risk’ profile for chronic BPD. In doing so, we would be able to identify which children are at ultrahigh risk for the development of BPD.

Another major research implication of a life span perspective on BPD is to investigate whether the new dimensional models of DSM and ICD-11 indeed are capable of capturing the changing expression of BPD across the entire life span [ 16 •]. Assessment of the AMPD with the SIPP-Sf and the PID-5 appears to be relatively age-neutral, except for the brief version of the PID-5. Therefore, the PID-BF should be examined in other populations, especially in clinical populations.

Furthermore, research could focus on the applicability of a life span clinical staging model for BPD, and on the added value of this model for selecting more appropriate interventions. The focus in treatment studies has been for too long on comparing specialized psychotherapies in adult BPD patients, but should turn to examining generic working mechanisms. Furthermore, there is a need to adapt specific treatment approaches throughout the life span, as they were designed for (young) adults and do not match with the needs of adolescents and older adults. Early intervention programs need to be developed and assessed for their efficacy across the entire life span. In the long run, early detection and intervention may prevent to a large extent that BPD evolves to a chronic stage in many cases, but for now we need to develop effective treatments for BPD in late life. This involves the adaptation of integrative treatments for older adults, but also behavioral management programs for old BPD patients in residential and home care.

Conclusions

There is accumulating knowledge on the onset and course of BPD across the life span. Our understanding of the onset and early course of BPD is growing, but knowledge of BPD in late life is still very limited. BPD first manifests itself in adolescence, and can be distinguished reliably from normative adolescent development. BPD symptoms and impairments continue to wax and wane up to old age, and their expression depends on contextual and developmental factors. The course of BPD from adolescence to adulthood is characterized by a symptomatic switch from predominantly symptoms of affective instability and impulsivity to maladaptive interpersonal functioning and enduring functional impairments, with subsequent periods of remission and relapse of the full categorical BPD diagnosis. Although the categorical criteria of DSM allow for reliable diagnosis of BPD in adolescence, dimensional models appear both more age neutral, and especially more useful in later life. To guide early intervention and better treatment selection across the life span a clinical staging model for BPD holds promise.

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Videler, A.C., Hutsebaut, J., Schulkens, J.E.M. et al. A Life Span Perspective on Borderline Personality Disorder. Curr Psychiatry Rep 21 , 51 (2019). https://doi.org/10.1007/s11920-019-1040-1

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12 Borderline Personality Disorder

• Published: February 2013
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Chapter 12 covers Borderline Personality Disorder (BPD), and includes definition and history of the condition, description and background of dialectical behavior therapy (DBT) used to treatm BPD, background history of the patient, assessment strategy, case formulation and treatment approach, course of treatment, treatment transfer specific to this case, relapse prevention, avoiding common mistakes in therapy, and case conclusions.

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The Borderline Grows Older

The difference age makes in bpd..

Posted August 24, 2013 | Reviewed by Ekua Hagan

In one study ( Journal of Psychiatric Research, 7/19/2013), both groups of symptomatic patients exhibited high levels of functional impairment and accompanying other diagnoses, such as depression or substance abuse . Younger adults (age 25 or younger) tended to be more impulsive, self-injuring, substance-abusing, and more emotionally labile. Older adults (45 and older) reported greater social dysfunction, more lifetime hospitalizations, and feelings of chronic emptiness.

Borderlines who do recover over time report a different experience. Researchers investigating the long-term evolution of borderline patients report that those who are considered fully recovered are more likely to marry and have children. These patients marry later in life and are less likely to get divorced than those who remain symptomatic. Successful marriage and parenting are associated with higher IQ , absence of childhood sexual abuse , no history of substance abuse, and extraversion .

These studies suggest that older and younger borderlines may present with different problems. We know that most of these patients improve significantly, but those who make commitments, such as marriage when younger and while acutely ill are less likely to sustain healthy relationships. Like many illnesses, allowing time to heal may be the best medicine.

Jerold Kreisman, M.D., is a psychiatrist and author of numerous books.

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At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

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Borderline Personality Disorder in the Elderly: A Case Study

• D. Siegel , G. Small
• Published in Canadian journal of… 1 December 1986
• The Canadian Journal of Psychiatry

9 Citations

Borderline personality disorder in late life, borderline personality disorder, clinical characteristics of older psychiatric inpatients with borderline personality disorder.

• Highly Influenced

Personality disorders in late life. Understanding and overcoming the gap in research.

Personality disorder in later life: a community study, psychodynamic perspectives on alzheimer's disease and related dementias, revising the personality disorder diagnostic criteria for the diagnostic and statistical manual of mental disorders-fifth edition (dsm-v): consider the later life context., personality dysfunction, coping styles, and clinical symptoms in younger and older adults, toward a unifying perspective on personality pathology across the life span, 9 references, the validity of dsm-iii borderline personality disorder. a phenomenologic, family history, treatment response, and long-term follow-up study., diagnosing borderline conditions in an outpatient setting., lifetime prevalence of specific psychiatric disorders in three sites., borderline: an adjective in search of a noun., borderline personality disorder: construct validity of the concept, psychoanalysis and psychoanalytic psychotherapy of the older patient. a developmental crisis in an aging patient: comments on development and adaptation., treatment of the elderly characterologically disturbed patient in the chronic care institution., self psychology and psychotherapy with the elderly: theory and practice., the faltering therapeutic perspective toward narcissistically wounded institutionalized aged., related papers.

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• Borderline personality disorder in the elderly brief review

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Due to current covid19 situation and as a measure of abundant precaution, our member services centre are operating with minimum staff, eissn: 2574-8130, gerontology & geriatrics.

Review Article Volume 3 Issue 5

Borderline personality disorder in the elderly: brief review

Glauco valdivieso jimenez function clickbutton(){ var name=document.getelementbyid('name').value; var descr=document.getelementbyid('descr').value; var uncopyslno=document.getelementbyid('uncopyslno').value; document.getelementbyid("mydiv").style.display = "none"; $.ajax({ type:"post", url:"https://medcraveonline.com/captchacode/server_action", data: { 'name' :name, 'descr' :descr, 'uncopyslno': uncopyslno }, cache:false, success: function (html) { //alert('data send'); $('#msg').html(html); } }); return false; } verify captcha.

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Psychiatrist, Psychotherapist, Center for Research, Teaching and Comprehensive Care in Mental Health (CENTIDOS) Lima, Peru

Correspondence: Glauco Valdivieso Jiménez, Psychiatrist, Psychotherapist, Treatment Program for Personality Limit Disorder according to the model of Dialectical Behavioral Therapy (DBT), Center for Research, Teaching and Comprehensive Care in Mental Health (CENTIDOS) Lima, Jr. Arequipa 133, Magdalena del Mar, Lima

Received: July 29, 2018 | Published: October 16, 2018

Citation: Valdivieso-Jiménez G. Borderline personality disorder in the elderly: brief review. MOJ Gerontol Ger . 2018;3(5):395-398. DOI: 10.15406/mojgg.2018.03.00153

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Borderline personality disorder (BPD) is a prevalent condition today. The studies carried out about its evaluation and treatment are aimed at the adolescent and adult population, however, there is not enough information in the elderly. In these, symptoms related to emotional instability and interpersonal performance predominate, different from the clinic of the categorical prototype in young people. No further research has been developed on effective treatment for this age group with personality disorder; however, it seems that the use of psychotropic drugs and psychotherapy is useful for those with associated comorbidities.

Keywords: borderline personality disorder, elderly

Introduction

Mental health problems in older adults are manifested differently than in young people, in addition the history of personality disorders that are not evaluated in time in any age group are a factor that complicates the clinical evolution of all patients. which motivates to carry out a review about the findings through different research work on the symptomatology, evaluation and treatment of these patients. This could contribute to the clinician to make a more detailed exploration of a probable borderline personality disorder in the elderly.

The main aim for this brief review is to standardize the knowledge obtained according to available information on the predominant symptomatology in older adults with a diagnosis of borderline personality disorder, the current status of the evaluation criteria and clinical issues.

A review of the current literature was carried out by searching for review articles and clinical research in Medline and Scielo, introducing the keys "borderline personality disorder", "BPD", “old age”, and “elderly”. The information was selected from 1996 to 2018. The critical review was made by the same author.

General view

The personality is defined as a biological, psychological, social, cultural and spiritual construct that governs the style tendencies in the emotions, cognitions and acts of subjects. It is shaped as you experience different situations in life (character) under an innate predisposition of action (temperament). The personality disorder is referred to the dysfunctionality of the predominant prototypical features present most of the time, chronically, alters interpersonal relationships, is alien to the culture of the subject and generates great discomfort. 1 , 2

On the other hand, borderline personality disorder (BPD) has a symptomatological core that is emotional instability, which leads the person's mental life leading to constant impulsive acts. Its prevalence in clinical samples within the categories of personality disorders in general, is 30-60%. It occurs more frequently in adolescent and adult women, although when presented in males there is the same severity. 2 , 3

At present, there is little information about the role of aging in the personality of individuals. Despite this, some studies report that the features and their characteristics that lead to classify it as a disorder, tend to decrease with age. The experience of some clinicians contradicts this, referring that, above all, in type B personality disorders, there is a moderate increase in risk patterns. Clinical experience suggests that BPD is more prevalent in the elderly than previously recognized, which agrees with limited available research. The prevalence of BPD in adults was 1.3% and 1.4% as indicated by a study. 4 , 5

Although the prevalence of BPD is higher in clinical populations than in the community, its information in psychiatric populations of advanced age is highly variable. One of the few studies like that of Widiger and Seidlitz (2002) concluded that the prevalence for the diagnosis of some personality disorder was 10% - 63%, in the same way Stevenson (2011) found that 60% of a small sample met criteria for personality disorder. 6 , 7

The main symptoms of BPD are impulsiveness, aggressiveness, suicidality, inappropriate anger, chaotic relationships, fear of rejection, emptiness feeling and cognitive / perceptual symptoms (micro psychosis, dissociation) being triggered by a constant pattern of emotional instability and this in turn, arises from an alteration of self and interpersonal functioning. However, these symptoms are based on the prototype found in the standard of adolescent patients and young adults. 8 – 10

In the prospective study by Zanarini (2012), McLean Adult Development Study (MSAD), found a pattern of improvement for some features of BPD over time, on all those corresponding to impulsivity and suicidal-parasuicidal behavior that dominates in adolescence, however these findings cannot be extrapolated to other populations because of the lack of them, but it is presumed that the experience throughout life in different contexts that test the maturity of people, are a stabilizing factor. 11

In old age, significantly lower levels of impulsivity, self-harm and substance use disorders are reported in the elderly population with BPD compared to younger adults. Because the most studied populations have always been adolescents and adults, when paying more attention to impulsivity there is less sensitivity in the diagnosis of personality disorders as age increases, based on the diagnostic guidelines available to all mental health professionals. However, self-harm occurs in younger patients, and those in the elderly, can occur in response to stress factors, especially as lack of psychosocial support. Suicidal threats are frequent, while suicidal gestures are much less so. Despite being uncommon, suicide attempts in elderly tend to be life threatening. 12 –15  

On the other hand, it has been described that the symptoms that persist with age are emotional instability and dysfunctional interpersonal relationships characterized by lack of empathy, generating chaotic environments in the home, work and other places corresponding to the context of the elderly. It has also been seen that there is a high prevalence of depression in old age that is often confused with the variable mood symptoms of BPD, assuming that its presence could affect its course and contribute to the predominance of negative affectivity. 16 –18

In the elderly, despite the psychic symptoms, there is a lower incidence of suicidal behavior, but a greater association with somatization, as well as devaluation in the content of the thought regarding life, its current condition and in some cases nonconformity with the treatment or health services. The frequent use of somatization is often expressed in dramatic and demanding complaints of medical attention. Studies pointed out that medical and psychopharmacological interventions associated with somatization can lead to prolonged admissions and generate conflicts with mental health staff ( Table 1 ). 19 –21

Table 1 Symptomatology in clinical groups in adolescence, adulthood and old age with BPD

Difficulties in assesment

There are many factors that prevent an adequate diagnosis in older adults. Of these we have the fact that there are no instruments available for evaluation and focus on young populations, absence of relatives that prevent the collection of biographical data, the coexistence of neurological / systemic diseases that overlap the diagnoses. There are only a few studies that apply the ICD 10 and DSM 5 diagnostic guides with non-significant samples. The difficulty is also found in the complexity of the course and evolution of the personality disorder considering it as a single entity since, according to the dimensional vision of it, it is opposed to the diagnostic categories and gives importance to the levels of severity as long time This is essential within the current discussions on the conceptualization of the personality and its disorder, since it would lead to the assumption that, if it is a variable alteration dimension in time, the severity of the symptoms would be less identifiable in the studies that are made cross-section, despite having been diagnosed in the past. 22 , 23

The management of personality disorder is of increasing interest in the field of mental health. The evidence is more numerous in borderline personality disorder in which psychotherapeutic and psychopharmaceutical models are included for the relief of symptoms. 24

It has been described that the lack of management in personality disorder, implies worse general clinical evolution in patients with diagnoses of comorbidity, being the case of major depression that is the most common in the elderly. 25 , 26

There are two publications of studies aimed to treatment of personality disorders in the elderly population. The first study was a randomized controlled trial in depressed elderly patients who had at least one comorbid personality disorder according to the Structured Clinical Interview for DSM-IV for Axis II (SCID-II) who did not respond to an antidepressant drug initially. Two groups were taken in which the pharmacological treatment was compared and in another adjunctive with dialectical behavioral therapy (DBT). However, the addition of DBT did not significantly improve depressive symptoms compared to medication alone. It is likely that there was a diagnostic confusion between personality disorder and depression. 27

The second study evaluated the efficacy of scheme therapy in 31 elderly patients with chronic depression and a personality disorder. It was found reduction of depressive symptoms and dysfunctional thinking schemes. 28 Therefore, taking into account the effectiveness of comprehensive treatment, ie the use of psychotropic drugs aimed at symptoms or comorbidities, and cognitive behavioral therapy (DBT) and psychodynamic psychotherapy, may be useful in this population in the same way as in younger populations. Its effectiveness should be studied further. 29

The combination of antidepressants with DBT has been described, the result of which was significant with respect to the improvement in interpersonal sensitivity and interpersonal aggression, in the post-treatment and 6-month follow-up compared with antidepressants alone. On the other hand, the addition of DBT did not significantly improve depressive symptoms in those with antidepressants alone. In both conditions, at least half of the subjects were in remission after having started medication, which makes it probable that there was confusion in the diagnosis with comorbid depression, because in previous studies it has been estimated that the medication in itself does not produce significant results. 30

It is important to emphasize that the studies to date have not provided us with reliable and truthful information about the phenomenology of BPD. It is likely that this is due to the heterogeneity of the investigations, the small samples of population, the scarce prior knowledge of the semiological evolution of personality disorders in general and which in turn influences the absence of sensitive instruments that manage to identify traits of dysfunctional personality in old age.

The controversy between categorical and dimensional vision is another reason it could affect the timely identification of personality disorders, as long as it continues to be considered in official manuals of general management among mental health professionals, this inefficiency and clinical ignorance of this age group will remain a vicious circle.

Regarding the limitations of the review, there is little information about borderline personality disorder in the elderly, so the most significant articles with more concise results that could be of better help for the preparation of the brief review have been chosen.

It is suggested to perform more studies on psychopathological findings in older adults with pathological personality or personality disorders in community samples, because it is difficult to find mental health problems related to personality as a first choice of elderly patients in hospitals or private clinics. This would allow to obtain more reliable epidemiological information that would help the clinician to identify a risk factor to complicate other mental comorbidities.

According to the information that is available to date, the following conclusions of borderline personality disorder in old age are stated:

• Predominance of emotional instability and dysfunctional interpersonal relationships.
• Predominance of depressive symptoms: depressive mood, devaluative thinking, somatization.
• Decrease in impulsivity, therefore, lower suicidality rate.
• There is absence of instruments available for the evaluation of borderline personality disorder in old age.
• Contrast in the model of categorical and dimensional diagnosis that limits the appropriate clinical judgment.
• It is recommended to carry out more studies based on the personality dimension, taking into account factors specific to the context of the individual.
• There is little evidence of the treatment of personality disorders in older adults, but psychotherapy seems to help reduce mood symptoms.

Self-financed.

Acknowledgements

Conflict of interest.

The author declares that there is no conflict of interests.

• Koldobsky NMS. Trastornos de Personalidad. Aspectos generales para su tratamiento. Editorial Polemos. Primera Edición. Buenos Aires, Argentina; 2009.
• American Psychiatric Association. DSM-5: Manual Diagnóstico Y Estadístico De Los Trastornos Mentales. 5th ed. Madrid. Editorial Médica Panamericana; 2014.
• Koldobsky NMS. Trastorno borderline de la personalidad: Un desafío clínico. Editorial Polemos. Primera Edición. Buenos Aires, Argentina; 2005.
• Beatson J, Broadbear JH, Sivakumaran H, et al. Missed diagnosis: The emerging crisis of borderline personality disorder in older people. Aust N Z J Psychiatry . 2016;50(12):1–7.
• Lenzenweger MF. Epidemiology of personality disorders. Psychiatric Clinics of North America . 2008;31(4):395–403.
• Widiger TA, Seidlitz L. Personality, psychopathology and aging. Journal of Research in Personality . 2002;36(4):335–362.
• Stevenson J, Datyner A, Boyce P, et al. The effect of age on prevalence, type and diagnosis of personality disorder in psychiatric inpatients. Int J Geriatr Psychiatry . 2011;26(9):981–987.
• Zanarini M. Borderline Personality Disorder. Taylor & Francis Group. New York; 2005.
• Borderline Personality Disorder. The NICE Guideline on Treatment and Management. National Collaborating Centre for Mental Health. The British Psychological Society and Royal College of Psychiatry; 2009.
• Livesley J. Integrated treatment: A conceptual framework for an Evidence-based approach to the treatment of personality disorder. J Pers Disord . 2012;26(1):17–42.
• Zanarini MC, Frankenburg FR, Reich D, et al. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: A 16-year prospective follow-up study. The Am J of Psychiatry . 2012;169(5):476–483.
• Cruitt PJ, Oltmanns TF. Age-related outcomes associated with personality pathology in later life. Curr Opin Psychol . 2018; 21:89–93.
• Oltmanns TF, Balsis S. Personality disorders in later life: questions about the measurement, course and impact of disorders.  Annual review of clinical psychology . 2011;7:321–349.
• Avari J, Mahgoub N, Mittal S, et al. A case series of elderly patients with borderline personality disorder and self-injurious behavior. The American Journal of Geriatric Psychiatry. 2011;19:S84–S85.
• Sadavoy J. Personality disorder in old age: Symptom expression. Clinical Gerontologist. 1996;16:19–36.
• Richa S, Ibrahim C. Course and stability of personality disorders in the elderly: A review. International Journal of Neuro psychopharmacology . 2012;15:238–239.
• Gunderson JG, Stout RL, McGlashan TH, et al. Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Arch Gen Psychiatry . 2011;68(8):827–837.
• Shea MT, Edelen MO, Pinto A, et al. Improvement in borderline personality disorder in relationship to age. Acta Psychiatrica Scandinavica . 2009;119(2):143–148.
• Arens EA, Stopsack M, Spitzer C, et al. Borderline personality disorder in four different age groups: A cross-sectional study of community residents in Germany. J Pers Disord. 2013;27(2):196–207.
• Sansone RA, Watts DA, Wiederman MW. Pain and pain catastrophizing among internal medicine outpatients with borderline personality symptomatology: A cross-sectional self-report survey. Prim Care Companion CNS Disord . 2013;15(5).
• Scheiderer EM, Wood PK, Trull TJ. The comorbidity of borderline personality disorder and posttraumatic stress disorder: revisiting the prevalence and associations in a general population sample.  Borderline Personal Disord Emot Dysregul . 2015;2:11.
• Stevenson J, Meares R and Comerford A. Diminished impulsivity in older patients with borderline personality disorder. The Am J Psychiatry . 2003;160(1):165–166.
• Stepp SD, Pilkonis PA. Age-related differences in individual DSM criteria for borderline personality disorder. J Pers Disord. 2008;22(4):427–432.
• Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry . 2001; 58(6):590–596.
• Alphen SPJ, Dijk M, Videler AC, et al. Personality Disorders in Older Adults: Emerging Research Issues. Curr Psychiatry Rep . 2015;17(1):538.
• Lynch TR, Morse JQ, Mendelson T, et al. Dialectical behavior therapy for depressed older adults: a randomized pilot study. Am J Geriatr Psychiatr . 2003;11(1):33–45.
• Kindynis S, Burlacu S, Louville P, et al. Effect of schema focused therapy on depression, anxiety and maladaptive cognitive schemas in the elderly. Encéphale . 2013;39(6):393–400.
• Lynch TR, Cheavens JS, Cukrowitz KC, et al. Treatment of adults with co-morbid personality disorder and depression: a dialectical behaviour therapy approach. Int J Geriatr Psychiatr . 2007;22(2):131–143.
• Videler AC, Rossi G, Schoevaars MH, et al. Effects of schema group therapy in older outpatients: a proof of concept study. Int Psychogeriatr . 2014;26(10):1709–1717.
• Alphen SPJ, Tummers JHA, Derksen JJL. Reaction to ‘Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach’. Int J Geriatr Psychiatr . 2007;22(7):702–703.

©2018 Valdivieso-Jiménez. This is an open access article distributed under the terms of the, Creative Commons Attribution License ,--> which permits unrestricted use, distribution, and build upon your work non-commercially.

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CASE STUDY Mary (borderline personality disorder)

Case study details.

Mary is a 26-year-old African-American woman who presents with a history of non-suicidal self-injury, specifically cutting her arms and legs, since she was a teenager. She has made two suicide attempts by overdosing on prescribed medications, one as a teenager and one six months ago; she also reports chronic suicidal ideation, explaining that it gives her relief to think about suicide as a “way out.”

When she is stressed, Mary says that she often “zones out,” even in the middle of conversations or while at work. She states, “I don’t know who Mary really is,” and describes a longstanding pattern of changing her hobbies, style of clothing, and sometimes even her job based on who is in her social group. At times, she thinks that her partner is “the best thing that’s ever happened to me” and will impulsively buy him lavish gifts, send caring text messages, and the like; however, at other times she admits to thinking “I can’t stand him,” and will ignore or lash out at him, including yelling or throwing things. Immediately after doing so, she reports feeling regret and panic at the thought of him leaving her. Mary reports that before she began dating her current partner she sometimes engaged in sexual activity with multiple people per week, often with partners whom she did not know.

• Concentration Difficulties
• Emotion Dysregulation
• Impulsivity
• Mood Cycles
• Risky Behaviors
• Self-Injury
• Suicidal thoughts

Diagnoses and Related Treatments

1. borderline personality disorder.

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Borderline Personality Disorder: Case Study

Lukenotes, summer 2021.

Sr. Rita was angry and frustrated after being asked to step down from a third committee in two years. She was informed that she was being removed from the welcoming committee because she was not very friendly or hospitable and might deter potential members from joining the community. Sr. Rita huffed off in disbelief and worked to control her rising anger. She marched to mother superior’s office prepared to plead her case.

How did Sr. Rita get here? Why has she been removed from yet another committee?

Sr. Rita struggles with fear of rejection and abandonment and insecurity about not being good enough. She has a history of impulsivity, aggression, and self-injurious behavior. At age sixteen, after an intense argument with her best friend, Sr. Rita attempted suicide by ingesting a bottle of pills. She briefly engaged in therapy but did not believe there was anything she needed to work on.

Sr. Rita has been in religious life for 22 years. As a child, she did not consider pursuing a religious vocation. In college Sr. Rita joined a Catholic youth group, volunteered at the local monastery, and sought guidance from a family friend in a religious community. Immediately following college, she joined a community in the Midwest and started her religious journey. Sr. Rita is happy with her decision and shows her love for religious life by getting involved, planning activities for the community and neighborhood, and suggesting ways to improve community living.

Initially, Sr. Rita embraced the quiet time for prayer and found the structure and routine helpful. More recently, however, she balks at not being able to coordinate her own schedule and does not always participate in community activities. She does not enjoy sharing a kitchen or car with other sisters and often fails to adhere to established rules. Some community members are afraid of Sr. Rita and shared their concerns with the superior. Sr. Rita seems unaware of her impact on the other sisters and becomes irate when concerns are expressed about her behavior. She was encouraged to utilize additional support and reluctantly agreed to meet with a Saint Luke Institute therapist.

Sr. Rita felt scared, yet relieved, when she received the diagnosis of borderline personality disorder. The diagnosis helped explain years of chaotic behavior. Although therapy was challenging, every day Sr. Rita gained new insight and skills. Most notably, through her work at Saint Luke Institute, Sr. Rita finally opened up about her traumatic upbringing. Sr. Rita lost her father in a car accident when she was eight years old. Her mother battled depression and stopped taking care of Sr. Rita and her siblings. One day Sr. Rita’s mother dropped her siblings and she off at church and never came back to pick them up. Sr. Rita still remembers the feeling and the moment when she realized her mother was not coming back to get them.

Sr. Rita’s traumatic and unstable childhood shaped the way she navigated the world. She was sensitive to any hint of abandonment due to feeling discarded by both of her parents. She existed in a state of hypervigilance as a means of self-protection and shut down her feelings to avoid reliving the terrible experiences from growing up in the foster care system.

With the support of trauma therapy, group counseling, and psychoeducation workshops, Sr. Rita slowly recognized how much pain she carried around and masked all those years. She replaced unhealthy coping skills with mindfulness and distress tolerance skills and identified triggers to create a process for difficult moments. Sr. Rita still struggles with managing expectations and receiving feedback, but continues to work with her therapist to better understand her behavior. Sr. Rita also creates more balance in her life by exercising, setting boundaries, and building time in her schedule for self-care.

As Sr. Rita continues the therapy work and practices therapeutic tools, her style of relating to others will improve, she will respond instead of reacting, and she will have greater control over her thoughts and feelings. Every day Sr. Rita reminds herself that healing is a process and a lifelong journey.

For confidentiality, reasons, names, identifying data, and other details of treatment have been altered.

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