Borderline Personality Disorder: Exploring the Etiology

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Biology 202

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Borderline Personality Disorder: Exploring the Etiology

Anna Dejdar

In one part of the book "Lost In The Mirror", Dr. Richard A. Moskovitz, M.D. writes, ""Elton John's characterization of Marilyn Monroe as a candle in the wind captures the essence of the borderline personality. She is an elusive character lacking in identity, overwhelmed by a barrage of painful emotions, consumed by hunger for love and acceptance, and careening from relationship to relationship and impulse to impulse in a desperate attempt to control these feelings"" (3). This portrayal vividly shows the key characteristics of Borderline Personality Disorder (BPD), which is a "Cluster B Personality Disorder". Personality Disorders are identified as being "pervasive, persistent, inflexible, maladaptive patterns of behavior that deviate from expected cultural norms" (1) and "the symptoms are seen in at least two of the following areas: Thoughts, Emotions, Interpersonal Functioning, Impulse Control" (2). BPD is a serious disorder that affects approximately 2-4% of the population in the United States (13). The DSM-IV, which is the Diagnostic and Statistical Manual of Mental Disorders and is used by the American Psychiatric Association (14) has a list of official criteria for diagnosing BPD. A person must have at least five of the following: "Intense and unstable personal relationships, Frantic efforts to avoid real or imagined abandonment, Identity disturbance or problems with sense of self, Impulsivity that is potentially self-damaging, Recurrent suicidal or parasuicidal behaviour, Affective instability, Chronic feelings of emptiness, Inappropriate intense or uncontrollable anger, and Transient stress-related paranoid ideation or severe dissociative symptoms" (4).

Furthermore, the description of Marilyn Monroe demonstrates one of the main characteristics of people with BPD which is that they have very low self-esteem and feel that they are worthless and as a result become extremely attached to someone that they are in a relationship with because of a fear of being abandoned by that person. They are clingy and need too much attention, becoming too much involved. Then the fear often becomes even more extreme and they actually begin to push the other person away from them and out of their life so that they will not be left. As a result of this treatment, the other person often does end up leaving. This act ends up validating the feelings of worthlessness that the person felt in the beginning. So this is a vicious cycle that keeps repeating for people with BPD and it becomes very difficult for them to get out of it and move away from those feelings. People with BPD can become so desperate that they might engage in self mutilation in order to try to get the other person to come back to them out of concern (5). As seen from this description, BPD has a lot to do with a person's thoughts and feelings about themselves and others, which makes it difficult to treat and also to identify the etiology (the cause) of it.

The exact etiology of BPD has not been found, but there are multiple theories; one is about childhood abuse and the other is a biological etiology. A very strong theory about the etiology is that people with BPD have suffered from early childhood trauma. It has been found that approximately 87% of people with BPD suffered from some sort of childhood trauma, 40-71% from sexual abuse and 25-71% from physical abuse. It has also been shown that when the abuse occurs early in the person's childhood, he/she has more damaging problems later in life. The explanation for this is that when the child is experiencing the abuse, he/she does not know how to make sense of what is happening, which then affects the thoughts and feelings of that person due to the confusion that he/she is feeling at that moment. The abuse also affects the relationships that the person will have in the future because he/she develops a difficulty in understanding the feelings and thoughts of others also and his/her relationship to other people. Another important part of this abuse is that while the abuse is occurring, the child seems to enter a "dissociated state" (4), where he/she no longer feels the pain as a way of defending themselves against the immense pain. This idea can be supported by the fact that one behavior that people with BPD demonstrate is that they cut their own body. It is reported that they do not feel any pain, which would suggest that they are also doing this in a "dissociated state" (4). Abuse in childhood also indicates that the family environment that the person is in can also play an important role because the families are not able to protect their child from the abuse or are doing the abuse to him/her, which shows that there are serious problems in the family, which could be another strong contributing factor (4).

The second theory of etiology consists of three different biological explanations for the development of BPD. The first one is that there is a problem in the limbic system, specifically in the amygdala and the hippocampus, in a person with BPD. Both the amygdala and the hippocampus are in charge of regulating the expression of emotions and particularly the expression of "fear, rage, and automatic reactions" (6). All of these are very important components in BPD, where the people have excessive anger and also fear in their relationships, which is demonstrated through impulsive acts like self-mutilation, which is an example of an automatic reaction. The limbic system in general is considered the "emotional centre" (6) of the brain. It has been found in studies that the volume of the amygdala and of the hippocampus are significantly smaller in people with BPD than in people who do not have any mental illness, indicating that there could be a link between BPD and a dysfunctional amygdala and hippocampus (6).

Another part believed to be involved is the orbital prefrontal cortex, which also has a very important role in regulating emotions. Particularly, it has been found that the orbital prefrontal cortex has a very important role with the inhibition of the limbic regions, which are concerned with generating aggression. The way that aggression is inhibited is through the serotonin system where the chemical serotonin regulates the activity in the prefrontal cortex and therefore when that is reduced, the problem with inhibiting that activity occurs (7). Therefore any damage to it could also result in emotional expression problems, which can definitely be seen in people with BPD as they move through very dramatic and severe emotions. One study done by Paul Soloff, M.D. and his associates found lower levels of glucose in the prefrontal cortex of people with BPD where glucose levels are associated with serotonin. If there are low levels of glucose, then that signifies that there is a deficient amount of serotonin (6), which could support the theory of the function of the serotonin system with the prefrontal cortex and BPD.

Another theory about the biological etiology of BPD looks at the function of the orbitofrontal cortex with BPD. One study compared people with BPD, people with lesions in the orbitofrontal cortex, people with lesions in the prefrontal cortex without lesions in the orbitofrontal cortex, and then a control group that consisted of "healthy subjects" (8). The study was looking at the possible etiology of BPD by giving all the subjects tests and questionnaires and comparing their performance or reactions and responses with people with BPD. The results and conclusions of this study were interesting because they introduced another possible aspect to the development of BPD. The researchers found that there were a lot of similarities between people with BPD and the people with orbitofrontal cortex lesions, particularly in the areas of the tests where they were both shown to be "more impulsive" (8) and reported "more anger and less happiness" (8) and more behaviors that were inappropriate than the other two groups. This would suggest that those aspects of BPD are related to a problem in the orbitofrontal cortex since both groups displayed the same responses in those areas. However, there were differences found between the two groups that suggest that not all of the traits of BPD are due to problems in the orbitofrontal cortex. For example people with BPD "were more neurotic, less extraverted, and less conscientious than all other groups" (8), even the group with lesions in the orbitofrontal cortex. Based on this finding, the researchers concluded that there must be a problem somewhere else in the brain that is responsible for these other aspects of BPD. They also suggested that this area might be in the limbic system, specifically in the amygdala, which is involved with emotion (8).

All of these theories with the etiology of BPD look at different explanations and point out various aspects of BPD that would explain BPD; however there does seem to be an interaction between all of them in relation to BPD. There is something known as the "diathesis-stress model" (14) in Psychology that states that in the development of an illness or disorder, there could be a relationship between a predisposing factor known as a "diathesis" and also the stress of the environment that that individual grows up in (14). This could be applied to BPD, where a person could have a problem in the orbitofrontal cortex or the orbital prefrontal cortex or the limbic system or in all of them, which would make him/her more susceptible to stressful situations in his/her environment. Then due to these problems, abuse or trauma in childhood could make the situation even more problematic and cause him/her serious problems in the future in the form of BPD. It could even be looked at in the reverse, where due to abuse or trauma in childhood, problems in the orbitofrontal cortex, the orbital prefrontal cortex or the limbic system could occur and then the person could develop BPD (6). This could explain why it is difficult to find the exact etiology because there are different factors that contribute to its development and not one specific factor that can be identified. Also, not everyone that has childhood abuse or trauma develops BPD, but other disorders or also no disorders, which would help to support the "diathesis-stress model", where the interaction between the two is what might be responsible for BPD (14). More research would have to be done to look at this and to see if this is the case.

BPD is a very difficult disorder and it affects both the people who suffer from it and also the people that are involved in their lives as it is challenging to help the person with BPD with his/her cycle of thoughts and emotions about his/her relationships and also his/her actions. There are various treatments offered for BPD ranging from therapy to medication. Five forms of therapy that are used are: Cognitive Analytic Therapy, Brief Psychoanalytic Psychotherapy, Interpersonal Psychotherapy, Dialectical Behavior Therapy, and also Schema-Focused Cognitive Therapy (4). Cognitive Analytic Therapy is that the therapist and the patient discuss possible connections between his/her present behavior and his/her childhood experiences. The therapist and the patient work together, which also helps to give the patient an example of a healthy and good relationship (4). Another therapy is Brief Psychoanalytic Psychotherapy, which has routes in Psychoanalytic Psychotherapy which was founded by Sigmund Freud where he used hypnotism and also "free association" in order to discover difficult memories that were suppressed by the patients (9). Brief Psychoanalytic Psychotherapy is a modified version of this where the therapist is specifically licensed in Psychotherapy and has a role that is very active in the treatment with the patient. They discuss his/her present experiences (4), (9). There is also Interpersonal Psychotherapy, where it also focuses on the present and helping patients with their personal activities and also their relationships (10). Then there is Dialectical Behavior Therapy, which is when the therapist helps patients with regulating their own emotions, and teaches them how to tolerate distress and also how to accept reality (11) while being very warm and understanding throughout the patient's process (13). Lastly, there is Schema-Focused Cognitive Therapy, where the therapist and the patient work on reshaping the patient's "maladaptive schemas" (4) which are negative thoughts and feelings that the patients have about themselves and their relationships with other people, which have started in their childhood and progressed throughout their lives (4). These therapies rely heavily on the new formed relationship between the therapist and the patient, which can be very helpful because it is founding a stable and long lasting relationship so that the person with BPD can feel more comfortable doing this in the future. However, a problem could occur because the patient might start his/her cycle of difficult relationships where the patient might get overly attached to the therapist. Then the BPD would be even harder to discuss and to treat because the therapist would be actually involved in the dysfunctional cycle (4).

Another technique as treatment is Eye Movement Desensitization and Reprocessing (EMDR), which is when the patient follows something that the practitioner is holding, with his/her eyes. The theory is that that these "rapid eye movements allegedly unblock ""the information-processing system"" (12) and this is a way of curing the brain (12) because it allows the central nervous system (13) to re-process the difficult memories and also to eliminate the previous beliefs. However, there is not strong evidence that supports this theory nor that the techniques with the movement of the eyes are the ones that really help with the problem. EMDR is a controversial treatment because many practitioners have been "certificated" to be able to do it; however the American Psychological Association has not approved of EMDR. Further research still needs to be done with EMDR to see if it is truly effective and to what extent it should be used (12).

Lastly, there is also the option of medication which consists of Selective Serotonin Reuptake Inhibitors (SSRIs), specifically antidepressants like Prozac and Zoloft. The antidepressants help with the very strong feelings of anxiety or despair that are experienced by people with BPD. There are also Mood –stabilizing drugs like Neurontin and lithium which aid with the radical and abrupt changes of mood that occur with people with BPD (13).

The therapies are all very different and apply to different people who might have different needs for dealing and treating their BPD and also if possible different causes of their BPD. There is a large range which would make it helpful for many different people. There are options for people who need to be able to discuss their thoughts and feelings or also medications as an option for people who feel that the problem is very biologically based and who need that help along with their therapies. The various therapies truly reflect the diverse and various explanations for BPD and are made adaptable to the people. There is still research to be done to look at the exact etiology of BPD and also possible relationships between the etiologies and also of effective treatments of BPD; however a lot of progress has been made that tries to effectively help with BPD. The theories have looked at various approaches to the etiology, embracing different options which shows that research is still open to understanding the cause.

WWW Sources:

1) eMedicine-Personality Disorders: Article by Michael S Beeson, MD, MBA ,

2)Personality Disorders Etiology, Symptoms, Treatment, and Prognosis ,

3)Exerpts From The Book: "Lost In The Mirror,

4)Recent developments in borderline personality disorder--Winston ,

5)Borderline Personality Disorder ,

6)Borderline Personality Disorder Label Creates Stigma ,

7)Mental Health InfoSource ,

8)Attentional Mechanisms of Borderline Personality Disorder ,

9)Complementary Health and Alternative Medicine- Psychotherapy ,

10)Interpersonal Therapy ,

11)Dialectical Behavioral Therapy ,

12)eye movement desensitization and reprocessing (EMDR) ,

13)Understanding borderline personality disorder ,

14) Butcher, James N., Susan Mineka, and Jill M. Hooley. Abnormal Psychology Twelfth Edition. Boston: Pearson Education, Inc, 2004.

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