Mental Illness Awareness Week is observed each year during the first week of October. In an effort to illuminate the darkness, Medical Daily turned to the Diagnostic and Statistical Manual of Mental Disorders, yet immediately stumbled. That massive book, published by the American Psychiatric Association, lists more than 200 forms of mental illness! Obviously, awareness is no simple matter, so Medical Daily will turn its small spotlight onto just one form: borderline personality disorder. Commonly misunderstood and easy to overlook, this disorder affects about 1.6 percent of all adults living in the United States.

Sitting on the Border

From a bird's eye view, any mental illness is a disease of the brain causing mild to severe disturbances in thought and/or behavior, according to the National Institute of Mental Health (NIMH). A mild form of mental illness may contribute very little to impairment while a severe disorder could substantially interfere with or even limit a patient's major life activities. In 2013, the National Institutes of Health estimated 43.8 million American adults (18.5 percent) had suffered with some form of mental illness in the past year, while an estimated 10 million adults (4.2 percent) had a severe mental illness.

In particular, borderline personality disorder is characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior, as described by NIMH. The name of this illness came about because the symptoms are considered to be on the borderline for several disorders. Specifically, the condition sits “on the border of major mood disorders and impulse control disorders,” said Dr. John Oldham, professor and executive chair, Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, in a discussion with NAMI.

“The main characteristics of this condition are emotion dysregulation and loss of impulse control and a lot of difficulties in interpersonal relationships,” Oldham explained. Dysregulation of emotion would mean a person becomes easily stirred up with intense emotions yet finds it difficult to put on the brakes. With inherited factors setting the stage for a lot of emotionality, a lot of impulsivity, and a lot of difficulty trusting other people, the (almost) inevitable results are mistrust, very difficult interpersonal relationships, and a great deal of instability.

Importantly, Oldham added there is “a very significant degree” of heritability, with borderline personality disorder being at about the same level of risk as conditions like some forms of heart disease and high blood pressure.

Diagnosis

There’s not just one type of person who would qualify for a diagnosis, this disorder covers a range of people who show “an enduring pattern” of at least five of these nine symptoms:

Extreme reactions — including panic, depression, rage, or frantic actions — to abandonment, whether real or perceived

A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)

Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future

Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating

Recurring suicidal behaviors or threats or self-harming behavior, such as cutting

Intense and highly changeable moods, each episode lasting from a few hours to a few days

Chronic feelings of emptiness and/or boredom

Inappropriate, intense anger or problems controlling anger

Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside, or losing touch with reality.

A common complaint about psychiatry in general is that each diagnosis is based on a set of symptoms, in many cases not even observed but self-reported symptoms. For the doubting Thomases, that’s not exactly convincing. However, since the advent of brain imaging technologies, scientists have amassed a mountain of neuroanatomical data, and, having peered inside the heads of patients with borderline personality disorder, they say some distinctive features can be seen.

Peek Inside the Brain

A recent review of borderline personality disorder neuroimaging research published since 2010 finds “structural and functional abnormalities in a fronto-limbic network including regions involved in emotion processing (e.g., amygdala, insula) and frontal brain regions implicated in regulatory control processes (e.g., anterior cingulate cortex, medial frontal cortex, orbitofrontal cortex, and dorsolateral prefrontal cortex).” The same review also suggests patients may have “altered function in neurotransmitter systems including the serotonin, glutamate, and GABA systems.” Commonly it is believed serotonin contributes to feelings of well-being, glutamate is involved more generally in brain function and cognition, while GABA is a chemical messenger that calms over-excited neurons.



Another study compared borderline personality disorder patients with healthy volunteers and reported deficits within fronto-limbic connections, specifically decreased white matter integrity in the cingulum and fornix — two separate bundles of fibers (white matter) that aid communication in the limbic system. Importantly, emotions form within the limbic system, which also plays a role in memory formation. “Abnormalities within the fornix and cingulum were related to severity of symptoms,” the scientists noted.



Generally, the disorder is treated with psychotherapy alone, though in some cases medication may be recommended to treat specific symptoms, such as depression or anxiety. However, no medications have been approved by the Food and Drug Administration, and only a few studies show that medications are necessary or effective, according to NIMH. That said, treatment can be effective as many people experience fewer or less severe symptoms over time.

To learn more about borderline personality disoder, watch this YouTube video from NIMH, featuring Dr. John Oldham: