Abstract
The purpose of this paper is to discuss diagnostic issues regarding Borderline Personality Disorder (BPD) and a biopsychosocial perspective of it. Also the purposes are to list risk factors, commonly co-occurring disorders, and differential diagnoses. Lastly, evidence-based therapies are described. BPD involves a variety of extreme emotional, cognitive, and behavioral symptoms. It is believed that BPD is a result of biological vulnerability and psychologically toxic environments which promote dysfunctional ways of thinking, feeling, and behaving. The main types of medications found effective in the treatment of BPD are SSRIs, anticonvulsants, and a combination of both. Psychotherapies that have been found to be effective are CBT including DBT, psychodynamic therapies including transference-focused and schema therapy, and interpersonal therapy.

Borderline Personality Disorder
Borderline Personality Disorder (BPD) involves impulsiveness, unstable relationships, self-image, and emotions (APA, 2000). These issues can be seen in behaviors such as desperate efforts to avoid abandonment (such as threatening to kill oneself if a partner is threatening to leave), a multitude of unstable and intense relationships, impulsive acts such as promiscuous sexual relations and reckless driving, recurrent suicide attempts and/or self-mutilations, feeling empty, excessive anger for a given situation, difficulty controlling anger, dissociation, and paranoid thoughts that come and go (APA).
As compared to people without this disorder, people with BPD tend to experience more unpleasant moods, are more submissive, more argumentative, and engage in more extreme thoughts, feelings and behaviors (Russell, Moskowitz, Sookman, Paris, & Zuroff, 2007). Kellogg and Young (2006) eloquently describe people with BPD as having “an inner theater in which the forces of cruelty, rage, submission, and self-numbing each take their turn on the stage” (p. 447). BPD) occurs in approximately 1-2% of the adult population and has been seen in cultures all over the world (APA, 2000). Approximately 75% of people diagnosed with BPD are female (APA). The purpose of this paper is to first discuss diagnostic issues and then explain BPD from a biopsychosocial perspective. Afterwards, risk factors, commonly co-occurring disorders, differential diagnoses, and evidence-based therapies will be described.

Diagnostic Issues
The term “borderline” was chosen to connote that a person is on the border between psychotic and neurotic disorders. Clearly, clinicians who have worked with people who have BPD have seen instances in which these people have dissociated and temporarily become psychotic. Other times, people with BPD engage in extreme thinking which causes extreme emotions that appear rather “neurotic.”
Flanagan and Davidson (2007) point out that it is important to realize that people “have” a disorder and that they “are” not the disorder. To make this difference obvious, they suggest that writers use discourse that connotes people having a disorder (i.e. people with BPD) rather than being a “BPD.” This distinction is important because having a disorder such as BPD comprises one part of a complex person rather than being a disorder that they are “…doomed to always possess” (p.101).
Although clinicians usually thought of BPD as a chronic and severe disorder, recent research suggests that it is not as enduring a pattern as previously thought. For example, Grilo et al. (2007) assessed 550 people with BPD at intake and two years later, and found that only 22% of these people who were assessed by clinicians blind to the diagnosis and purpose of the study met the criteria for BPD at the 2 year follow up period. There was no mention of whether these people engaged in any form of treatment during the interim. It is also interesting to note that 54% of the Grilo et al.’s participants met the criteria for affective instability, 43% for inappropriate anger, and 36% for impulsivity. Although the least frequently found criteria in Grilo et al.’s study were suicidal ideation and self mutilation (26%), these criteria were also the best predictors of future diagnosis of BPD. This finding seems logical as it suggests that the people with the most severe symptoms of BPD are also the ones most likely to have this disorder two years later. It is also important to note that although people with BPD often express suicidal ideation, just under 8% (94/1179) of people with BPD actually committed suicide in one large archival study (Pompili, Girardi, Ruberto & Tatarelli, 2005).
Not surprisingly, people with BPD tend to have a lower quality of life on psychological and social factors than people without this disorder (Perseius, Andersson, Asberg & Samuelsson, 2006). One reason for this lowered quality of psychological and social factors is the relationship dynamics they create in their families. For example, people with BPD tend to have intense relationships with insecure attachment (Aaronson, Bender, Skodol, & Gunderson, 2006). They tend to be intensely dependent on others to meet their emotional needs such that they become enmeshed (Aaronson et al., 2006). When they think that the intensity of their bond with someone decreases, and most people can not withstand the extreme intensity that many people with BPD require, the person with BPD becomes frustrated and then engages in angry withdrawal and rage (Aaronson et al., 2006). Thus, their relationships typically vacillate between “compulsive caregiving and angry withdrawal” (Aaronson et al., 2006). Interestingly, people with BPD also tend to have lower quality of life on physical factors as well. In other words, they tend to have poorer physical health even after age is statistically controlled (Perseius et al. 2006).
BPD is coded on Axis II of the Diagnostic and Statistical Manual (DSM) (APA, 2000), however the distinction between Axis I and II is not as clear as originally conceptualized. Previously, before the technological advances that are used today (i.e. fMRI, CAT scans, PET scans etc.), illnesses that were generally conceptualized as having a biological and transient basis were coded on Axis I, whereas disorders thought to have a psychological basis and a relatively stable course were coded on Axis II (Ruocco, 2005). However, as can be seen below, BPD, as with other disorders, has both biological and psychological etiologies and therefore, the distinction between the two axes, based on a rather polar etiological view of BPD, seems inadequate (Ruocco).

Comorbidity
Commonly co-occurring disorders are substance abuse (Feske, Tarter, Kirisci, & Pilkonis, 2006), ADHD (Miller, Nigg, & Faraone, 2007) PTSD (Brunet, Akerib, & Birmes, 2007) major depression (Bellino, Zizza, Rinaldi & Bogetto, 2007), mood disorders (APA, 2000) especially Bipolar II (Utsumi et al., 2006), other personality disorders (APA, 2000), eating disorders (Bourke, 2006), and Post Traumatic Stress Disorder (PTSD) (Brunet, Akerib, & Birmes, 2007).
Feske et al. (2006) found that in a sample of 232 women recruited from a psychiatric clinic, BPD was a statistically significant predictor of developing a substance abuse disorder, including abuse of alcohol, heroin, cocaine, and poly-substance abuse. It is interesting to note that only antisocial personality disorder produced larger probabilities for the development of a substance abuse disorder than BPD (Feske et al.). Also, histrionic personality disorder was the third best predictor (among personality disorders) of development of a substance abuse disorder (next to antisocial and borderline).

Differential Diagnosis
BPD should be differentiated from other personality disorders such as Histrionic, Schizotypal, Paranoid, Narcissistic, Antisocial and Dependent (APA, 2000). In addition, the clinician needs to determine whether the client suffers from a personality change attributable to a general medical condition.
Eubanks-Carter and Goldfried (2006) studied 141 American psychologists with an average of 26 years of experience. These psychologists were given a vignette of a hypothetical client who presented with symptoms that were similar to both BPD and sexual identity crisis. Variables that were manipulated were client gender and sexual orientation (unspecified, bisexual, gay/lesbian and heterosexual). They found that when the hypothetical client was female, the sexual orientation did not significantly affect therapists’ diagnosis of BPD. However, when the hypothetical client was male, and was perceived to likely be gay or bisexual, clinicians were more likely to diagnose them as having BPD (Eubanks-Carter & Goldfried, 2006). This finding may suggest that clinicians may inadvertently perceive of people who are either bi- or homosexual as being more disordered than people with a heterosexual preference.

Biopsychosocial Conceptualization
BPD is thought to result from a biological vulnerability that stems from genetic and environmental conditions that creates heightened emotional sensitivity and dysregulation and an upbringing from unresponsive parents (Lynch et al., 2006) or caregivers that neglected or abused them (Fonagy & Bateman, 2006). More specifically, people with this disorder tend to have caregivers that did not validate or reflect their emotions (Fonagy & Bateman). Closely related to these ideas, Linares (2006) hypothesized that children in a family who do not receive nurturing but instead live in a chaotic environment in which love is obstructed by power, tend to develop BPD. Kellogg and Young (2006) hypothesized that people with BPD tend to have families that are unsafe, unstable, depriving, harshly punitive, rejecting, and/or subjugating that tend to abuse and neglect the children. In general, the biological factors set the stage for the psychological factors to play roles that contribute to the development of BPD.

Biological Etiological Factors
There are several factors that contribute to the development of biological vulnerability to BPD. For example, a dysfunctional serotonin regulation system has been hypothesized to be one component of the impulsivity and aggressiveness often seen in people with BPD. Ng et al. (2005) compared 21 females with BPD to 21 matched controls without this disorder and found that the females with BPD had a very statistically significant (i.e. p < 00001) lower platelet paroxetine binding than the controls, which is indicative of serotonin dysfunction at the presynaptic stage.
In a review of the literature, LeGris and Reekum (2006) found that 83% of people with BPD had neuropsychological impairment linked to the dorsolateral, prefrontal, and orbitofrontal regions of the brain. Brain functions associated with these areas that are most often impaired in people with BPD are response inhibition, decision making, visual memory, attention, verbal memory, and organization of visuospatial stimuli. Functions that are usually not impaired in people with BPD are spatial working memory, planning and intelligence (LeGris & Reekeum). LeGris and Reekum also found that people with BPD tend to do worse on the Stroop Test and the Wisconsin Card Sort than those that did not have this disorder.
Grosjean and Tsai (2007) found that people with BPD had dysregulation of NMDA transmission which plays an important role in neuronal plasticity, thinking, and memory. These findings may provide some biological underpinnings to the rigid thinking often displayed by people with BPD. Described as the “missing link,” Williams, Sidis, Gordon and Meares (2006) found that people with BPD have distinct breakdowns in integrating networks in the posterior and frontal areas. These breakdowns may help explain why people with BPD tend to have problems with emotional dysregulation and impulsivity.
Many researchers have found that people with PBD tend to have dysfunctional serotonin regulation, which is related to impulsiveness, aggression, and depression. For example, BPD, childhood abuse, and the T allele of GNB3 that transports and promotes serotonin were significantly related (Joyce et al., 2006; Steiger et al., 2007). Associations were stronger in younger than older people with BPD (Joyce et al.) Koch et al. (2006) found that eight nonmedicated people with BPD had more dysfunction in their serotonin systems (promotion and transportation) than the comparison group who did not have BPD. Furthermore, Steiger et al. (2006) also note that people with BPD who have a history of abuse had greater pathology in the S allele carriers responsible for transporting and promoting serotonin than the comparison group who did not have BPD.
In addition, not only are serotonin systems dysfunctional, neuroimaging has shown that people with BPD show neuro-structural differences. In a review of the neuroimaging literature, Lis et al. (2007) conclude that many people with BPD have reduced volumes in mainly the amygdala that may be related to inhibitory neurons that have lost their ability to function. This means that, like a horse and rider, the brain structures responsible for the emotional regulation are running wild like a horse out of control and the other inhibitory cognitive structures (the rider) that should regulate it (such as in the frontal lobe) are either asleep, paralyzed or otherwise unable to reign in the horse’s chaotic activity (Lis et al.).

Psychological Etiological Factors
One of the most prevalent contributing factors to the development of BPD found in the literature is dysfunctional childhood issues. For example, most people with this disorder have experienced extreme abuse either emotionally, physically, and/or sexually (i.e. Watson, Chilton, Fairchild, & Whewell, 2006). One of the most important factors in predicting the development of BPD in adulthood is the fear of or actual abandonment in childhood, which can also lead to the development of insecure attachment style (Aaronson, Bender, Skodol, & Gunderson, 2006).
It is important to note that emotional abuse and neglect were as powerful of predictors of dissociation in people with BPD as physical and sexual abuse were (Watson, Chilton, Fairchild, & Whewell, 2006). In people with BPD, level of trauma experienced during childhood was not surprisingly positively associated with levels of dissociation. It is interesting to note that alcohol substance abuse disorders predict the development of BPD in adulthood (Thatcher, Cornelius, & Clark, 2005).
Communication problems are also very prevalent in families in which children develop BPD in adulthood. Kirsten, Lellyveld and Venter (2006) conducted a qualitative study of families that have members who have BPD and found that relationships amongst family members tended to be unstable, emotionally intense, and ambivalent. Kirsten et al. observed verbally abusive interactions, intimacy deficits, dysfunctional boundaries, poor parental modeling of behavior control and coping, and poor problem solving. They noted that fulfillment of emotional and other needs tended to be precluded by rigid and reversed roles (Kirsten et al.).
People with BPD tend to have a negative and unstable sense of self, have stronger emotional reactions to real or imagined threats of abandonment (Zeigler-Hill & Abraham, 2006) tend to have deficits in their ability to solve social problems (Kremers, Spinhoven, van der Does, & van Dyck, 2006) and have a low tolerance for distress (Gratz, Rosenthal, Tull, & Lejuez, 2006). Janis, Veague, and Driver-Linn (2006) compared people with BPD to people without a personality disorder. After matching the participants on age and other variables, Janis et al. found that people with BPD had an unstable and negative sense of self.
People with BPD are much more sensitive to other people’s emotional reactions, probably as a result of their fear of abandonment and other reactions to childhood trauma. Lynch et al. (2006) found that people with BPD were able to detect change in emotional expression, regardless of whether the emotion was changing into positive or negative expressions, much sooner than people without this disorder. Lynch et al.’s study was an interesting way to measure and quantify people with BPD’s emotional sensitivity.
Gregory (2007) suggests that BPD is a result of a pathological self-structure. He suggests that people with BPD attempt to create meaning and to end their struggle with ambiguity by using polar thinking. For example, people with BPD tend to think in extremes such as others are either ideal or worthless, things are all good or all bad, they are all powerful or all helpless, and they are dependent or independent without consideration for the possibilities between the extremes (Gregory). He suggests that people with BPD use polar thinking with most of their ways of conceptualizing their values, abilities, and motivations. Gregory hypothesized that this polar thinking originates from abused children’s thinking that protects them from rejecting their abusive caregivers, whom they need, by preserving the fantasy of an ideal caregiver through denying the abusive characteristics. This dysfunctional schema of thinking is then carried forward to adulthood if it goes unchallenged.
Therefore, the development of BPD in adulthood is a complex process starting with biological vulnerability and psychologically toxic environments which promotes the person’s use of dysfunctional ways of thinking, feeling, and behaving. These dysfunctional ways lead to the person with BPD experiencing a lot of distress. Paradoxically, the person with BPD is usually unaware that much of the distress they experience is self-created.

Risk Factors
As can be seen from the above literature review, the main biological factors that would place a person at risk of developing BPD would be dysfunctional serotonin regulation systems which may be partly due to genetics and/or trauma (Steiger et al., 2007), poor neurological ability to integrate information in different parts of the brain (Williams et al., 2006), and reduced ability of the amygdala and associated emotional centers to regulate emotion (Lis et al., 2007). Psychological factors that place a person at risk of developing BPD are any type of abuse or neglect during childhood, especially abandonment (Aaronson et al., 2006), communication in a dysfunctional family system (Kirsten et al., 2006), extreme emotional sensitivity which is a product of neuropsychological and environmental factors as well as extreme thinking style (Lynch et al., 2006; Zeigler-Hill & Abraham, 2006), and low distress tolerance (Gratz et al., 2006).

BPD Therapy
Therapy for people with severe BPD usually involves medication and psychotherapy. However, it is hypothesized that people with severe BPD are also much less likely to take their medications and engage in psychotherapy than people with other psychological issues as the very nature of BPD predicts treatment noncompliance (Nel & Smith, 2006). For example, people with BPD may be noncompliant by rejecting the medication as a symbolic rejection of the prescriber, as people with BPD usually go through extremes of idealizing and devaluing their service provides. When idealizing their service providers, they may be compliant with medications and while devaluing them they may reject the medication. In addition, their extreme all or nothing thinking might lead them to believe that if they do not feel immediate relief from medication and psychotherapy they may abandon treatment. Furthermore, their instability of self may lead to variable motivation to change in therapy, thus some days they may feel motivated, powerful, and self-efficacious such that they take medication and engage in psychotherapy and other times they may give up and think of themselves and their treatment as worthless and useless. In sum, people with BPD’s motivation for treatment may fluctuate drastically between idealizing and devaluing treatment such that they drop out early.

Psychopharmacological Treatment
If psychiatrists and psychologists can get people with severe BPD to complete pharmacological and psychotherapeutical treatments, chances are that this combination could be effective in reducing symptom severity. For example, Bellino, Zizza, Rinaldi, and Bogetto (2006) compared groups of people who were depressed and had BPD who were either taking Fluoxetine (a Selective Serotonin Reuptake Inhibitor, SSRI), engaging in interpersonal psychotherapy, or both. Not surprisingly, the group that had the combined medication and psychotherapy showed the best treatment gains (Bellino et al.).
In a review of the literature, Cardish (2007) found that SSRIs such as Fluoxetine were helpful in reducing depression, anxiety, distress, and anger in people with BPD. Another SSRI, Fluvoxamine, was helpful in reducing rapid mood shifts (Cardish). Neuroleptics (such as Flupenthixol Deconate, Trifluoperazine, Risperidone, and Quetiapine) have been found to be helpful in reducing suicidal, self-harming behaviors, and impulsive aggression (Cardish). Anticonvulsants such as Oxcarbamazepine and Divalproex have been associated with reduced interpersonal problems, impulsivity, impulsive aggression, hostility, emotional dysregulation, and anger (Cardish). For clients who tend to not have a response to SSRIs or neuroleptic medications, a combination of both of these types of medications can lead to some relief (Cardish). As a last resort when other medications and psychotherapies have not helped and the client is extremely suicidal, ECT (Electroconvulsive Therapy) has been used with good success rates (Cardish).
Other researchers have found that the atypical antipsychotic Quetiapine has been helpful in reducing psychosis, impulsivity, and depression in people with BPD (Gruettert & Friege, 2005). Topiramate was effective in reducing anger and aggression in women with BPD (Cardish, 2007; Loew, Nickel, Muelbacher, 2006). It is interesting to note that a nonmedicinal therapy, Omega-3 fatty acids, has been associated with reduced aggression and depression in people with BPD (Zanarini & Frankenburg, 2003).

Psychotherapy
Cognitive Behavioral therapy (CBT) is one of the most effective therapies for people with BPD (Wenzel, Chapman, Newman, Beck, & Brown, 2006). CBT mainly involves identifying and disputing dysfunctional thinking. People with BPD tend to think in extremes and extreme emotion tends to result from those thoughts. Therefore CBT, is very effective in addressing these thinking errors (Wenzel et al.) Other aspects of effective CBT involve developing emotion management and interpersonal skills and reducing hopelessness (Wenzel et al.).
Lynch et al. (2007) suggest that many people with BPD can not tolerate standard CBT as it usually involves a lot of confrontation. Due to their heightened sensitivity, many of these clients can not tolerate a lot of confrontation as they may misperceive it as rejection and it may feel reminiscent of the invalidating environment in which many of them grew up in (Lynch et al.). A type of CBT that uses specific types of confrontation designed for people with BPD, known as Dialectical Behavior Therapy (DBT), has been shown to be one of the most effective therapies for people with BPD (Lynch, Chapman, Rosenthal, Kuo & Linehan, 2006). For instance, in a study of ten people with BPD, Brassington and Krawitz (2006) found that after six months of DBT, clients experienced reduced levels of anxiety and depression, improved scores on the Global Severity Index and less hospital bed days per year after treatment. In her review of the literature on treatment of BPD, McCain (2007) found that DBT and psychodynamically oriented treatment were the most effective treatments for reducing self-harm in people with BPD. However, Levy et al. (2006a) found that more people with BPD who had engaged in one year of transference-focused therapy changed their beliefs to that of a secure attachment than people who engaged in one year of DBT or one year of psychodynamic supportive therapy.
The goal of DBT is to help clients replace dysfunctional strategies (such as self-harm and parasuicidal behaviors) that they use to meet their needs with effective strategies that will not normally lead to anger and abandonment by those people living and working with them (Jones & McDougall, 2007). DBT involves balancing acceptance of clients the way they are in order to feel validated with confrontation/change (Lynch et al.).
To address dysfunctional ways of obtaining needs and emotional dysregulation, strategies such as mindfulness, validation, self-monitoring/analysis of self harm, dialectics and emotion management skills are taught and practiced in individual and group therapy (Jones & McDougall, 2007). Mindfulness involves keeping one’s mind aware in the present moment, thinking without judgment, and finding the grey areas between the black and white areas of their thinking (Lynch et al.). Validation refers to finding a grain of truth in the client’s statement and agreeing with it such as noting the logic behind dysfunctional behavior (Lynch et al.). Validation helps clients remain in therapy as they feel listened to and understood (Lynch et al.). In addition, self-monitoring involves teaching clients to do a detailed functional analysis (i.e. analyzing the precedents, antecedents, and needs met) of their self-harm and other behaviors (Lynch et al.).
Sachsse, Vogel, and Leichsenring (2006) conducted psychodynamic and EMDR treatment with 75 German inpatients who had PTSD and BPD. They found that after treatment, there was a significant decrease in self-harm and hospitalizations with an impressive effect size of 2.88 (approximate range of effect size is -4 to +4). They also found that treatment gains were maintained at one-year follow up.
Another type of therapy found to be effective in treating people with BPD is Interpersonal therapy (Markowitz, Skodol & Bleiberg, 2006). Interpersonal therapy was developed from the theory that the healthiness of early and current relationships is significantly related to mental health outcomes (Markowitz et al.). Clients learn to identify and monitor interpersonal situations that impair the formation and maintenance of relationships and then learn better interpersonal skills (Markowitz et al.). Each session is spent reviewing the client’s homework which is monitoring these interpersonal situations (Markowitz et al.). The therapist reinforces the effective skills and teaches and role plays skills the client requires (Markowitz et al.).
Kellog and Young (2006) advocate schema therapy for people with BPD. This therapy is based on cognitive-behavioral, attachment, psychodynamic, and emotion focused therapies. They conceptualize people with BPD as needing to reorganize their inner schemas through re-parenting, imagery and dialogue, cognitive restructuring, psychoeducation, and breaking old patterns. They suggest that people with BPD have four modes of behavior that need to be restructured in therapy: the abandoned child mode, the angry impulsive child, the detached protector mode, and the punitive caregiver mode. During schema therapy, clients learn to adopt the healthy adult mode.
Trippany, Helm, and Simpson (2006) suggest that self-mutilation behaviors may be reenactments of sexual abuse and that the focus for BPD may need to be on unresolved issues rather than personality restructuring. Other clinicians suggest transference-focused therapy in which clients learn to integrate thoughts and feelings that were previously compartmentalized and disorganized (Levy et al., 2006b). Therapists become highly engaged and emotionally intense as a way to model the ability to accept intense emotion. It is hypothesized that because of these split off emotions, people with BPD tend to have extremely polarized views of themselves and others (Levy et al., 2006b).
In summary, people with severe BPD tend to respond better to a combination of medications and psychotherapy. The main types of medications found effective in the treatment of BPD are SSRIs, anticonvulsants, and a combination of both. As a last resort when nothing else works, ECT has been found to be helpful. Psychotherapies that have been found to be effective are CBT including DBT, psychodynamic therapies including transference-focused and schema therapy, and interpersonal therapy.

Conclusion
In summary, BPD involves a variety of extreme emotional, cognitive, and behavioral symptoms that include unstable and intense relationships and self-mutilation (APA, 2000). Although once thought of as a chronic and severe disorder, only about 22% of people with this disorder will be diagnosed with it two years later (Grilo et al., 2007). Commonly co-occurring disorders are substance abuse, ADHD, depression, other personality disorders, eating disorders, and PTSD. It is hypothesized that the development of BPD in adulthood is a complex process starting with biological vulnerability and psychologically toxic environments which promotes the person’s use of dysfunctional ways of thinking, feeling, and behaving. These dysfunctional ways lead to the person with BPD experiencing a lot of distress. Paradoxically, the person with BPD is usually unaware that much of the distress they experience is self-created.
To address the emotional upset and distress that people with BPD usually experience, a combination of medications and psychotherapy are usually effective. The main types of medications found effective in the treatment of BPD are SSRIs, anticonvulsants, and a combination of both. As a last resort, ECT has been found to be helpful. Psychotherapies that have been found to be effective are CBT including DBT, psychodynamic therapies including transference-focused and schema therapy, and interpersonal therapy.

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