Symptoms of Borderline Personality Disorder

Borderline personality disorder is distinguished by a range of pathological symptoms which include unstable affective states that affect interpersonal relationships as well as their behaviour[1]. These symptoms make their first appearance sometime in adolescence, and continue to appear chronically throughout adult life if left untreated[2]. People suffering from this mental disease set unrealistic expectations for relationships by idealizing the person they admire and offsetting overwhelming fears of rejection and abandonment[3]. Therefore when actual or imagined neglect is perceived, the ego of the patient undergoes self-depletion which causes them to view themselves as worthless[3]. Patients also display signs of impulsive and reckless behaviour, which includes, but is not limited to, gambling, substance abuse, binge eating and sex[3]. This may lead to engaging in recurring self-harming behaviours, possibly resulting in suicide[3]. Altogether, these symptoms make it challenging for borderline personality disorder patients to maintain a relationship with any other person.

Borderline Personality Disorder
A quick introduction to borderline personality disorder and its symptoms.
Adapted from (Ofir Sasson, 2013)[17].

Unstable Emotional States

Dysphoric Affects and their Progression

Patients with borderline personality disorder struggle with intense emotional states, which are usually dysphoric or malcontent affects. These negative feelings vary between, but are not limited to, feelings of anger, regret and sadness, extreme fear, and chronic emptiness and abandonment[4]. In comparison to healthy controls, borderline individuals experience negative dysphoric states at a greater severity[5], and take more time to return to their baseline emotional state[6]. These unstable emotional states may be a physical manifestation of the inner distress experienced by the patient[5] and may arise due to increased sensitivity to rejection[3] and vulnerability to negative interpersonal cues[6].

The course of these dysphoric affects varies depending on the situation of the borderline personality individual. Studies have shown that borderline patients who undergo treatment experience more mild dysphoric affects in comparison to individuals who do not get treated [5]. Another factor that affects the course of dysphoric affects is the amount of negative stimuli to which the borderline patient is exposed to[5]. Dysphoric states seem to reoccur regularly, preventing positive motivation and social interactions, which are necessary for proper recovery[5]. A greater exposure to these dysphoric states decreases the individual’s self-confidence, and consequently hinders their ability to recover[5].

Affected Brain Structures

It is hard to determine the structural differences in patients with BPD, since studies tend to contradict each other. Although the abnormalities appear to be in the same regions, various studies present different results. In the case of emotional dysregulation, irregularities in the prefrontal cortex, hippocampus and the amygdala are significant factors. The prefrontal cortex, which contributes to affect regulation[7], has been shown to be underactive in borderline personality subjects[8]. A study by Bruehl et al. (2013) observed an increase in the thickness of the dorsolateral-prefrontal cortex, amongst its borderline personality subjects, in comparison to healthy controls. Factors such as age have shown different effects[8]. For instance, in adults, there is a decrease in volume as well as gray matter density in the orbitofrontal cingulate and anterior cingulate[8]. However, in teenagers, the decreased gray matter appears to be in the dorsolateral-prefrontal cortex[8]. In 2008, Soloff et al. reported hippocampal volume decrease in borderline personality patients due to loss of gray matter[7]. This was especially true in the case of borderline females with a history of childhood trauma or abuse, or who had a history of several hospitalizations[7].

Decrease in Gray Matter Concentration in Borderline Individuals
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Adapted from Soloff et al.(2008)[7] (a) Loss of gray matter in hippocampus of borderline individuals.
(b)Loss of gray matter in hippocampus of borderline females. (c) Loss of gray matter hippocampus of sexually abused borderline females.

The hippocampus is responsible for making associations between present perceptions of reality and the memories of the past, and regulating the emotional state accompanied with these memories[7]. Since borderline personality patients suffer from the effects of an impaired hippocampus, they are incapable of suppressing the dysphoric affects when presented with a situation that triggers a traumatic memory from their past Research about the amygdala in the borderline personality brain is the most controversial. Some studies conclude that the amygdala is hypoactive, while others contradictorily conclude that it is hyperactive, especially in response to negative stimuli[7]. Despite these divergent results, researchers on the dysphoric affects in borderline subject have concurred that the amygdala-hippocampal-prefrontal cortical circuits must be intact in order to properly process emotion[7].

Abnormal Cognition

Impaired Theory of Mind

Individuals possessing theory of mind when they are capable of recognizing that every individual has their own distinct mental state, thoughts, perceptions, beliefs. Theory of mind is the cognitive ability to understand another person’s emotional state, opinion or knowledge regarding a certain topic or situation through non-verbal cues, such as facial expressions or body language, and other sources[9]. Individuals with borderline personality disorder are thought to have superior Theory of Mind and emotional intelligence, despite their own unstable emotional states and interpersonal relationships[9][10]. This phenomenon has been named the Paradox Hypothesis[9][10].

Hypersensitivity to Emotions

The paradox hypothesis has been supported by multiple studies, however the results of the studies vary on the type of emotional cues recognized by the borderline subject. In order to assess the effects of hypersensitivity, clinicians will administer the Facial Emotion Recognition test. Results have shown that borderline subject have trouble identifying negative affects such as anger, disgust or unhappiness, in comparison to healthy controls[10]. Using the same method, other studies demonstrate a weak performance by the borderline patients when identifying neutral or ambiguous facial expressions, as well as when trying to understand combined emotional stimuli such as vocal and facial emotional cues[10]. They were also able to conclude that in comparison to healthy controls, borderline patients are quicker and more accurate when identifying faces with fearful facial expressions, indicating an increased sensitivity to this emotion[10].

Another method used to study hypersensitivity in borderline personality individuals is the “Reading the Mind in the Eyes Test” (RMET). This method evaluates how well an individual is able to distinguish various mental states using only cues from the eyes and eye region[9]. Once again, results from this method have been inconsistent. Fertuck et al. (2009)’s results indicated that borderline subjects identify neutral and positive gazes accurately, but they do not do well when faced with negative gazes[10]. In a similar study by Frick et al. (2012), the borderline patients identified positive and negative gazes accurately, but had trouble with neutral gazes[9]. They were also quicker when responding to cues relative to healthy controls, which may indicate that they are responding in a more intuitive fashion[9].

The reasons for the conflicting results are numerous. They are likely due to inconsistencies across different methodologies, such as the amount of time the face is displayed to the subject, or confounding variables, such as the socioeconomic status and levels of education of the participants[10].

Although these studies are inconclusive, they indicate that borderline individuals have trouble discerning possible threats. They recognize negative facial cues quickly and accurately because they immediately perceive them to be threatening[10]. However, when presented with neutral or ambiguous facial cues, borderline subject have difficulties accurately understanding them because they also assume these facial expressions are threats[10].

Abnormal Amygdala Structure

Although the research on hypersensitivity overall is obscure, studies have concluded that atypical amygdala activity is involved when borderline subjects are mentalizing emotions. The amygdala is known to evaluate facial expressions of others, and induce feelings fear and anxiety if a threat is detected [7]. Functional magnetic resonance imaging studies illustrate hyperactivity in the amygdala when the borderline individual is looking at certain facial expressions. The facial expressions that trigger this hyperactivity are not conclusive; different studies suggest different emotional cues to which borderline patients respond. Fertuck et al.’s study (2009) indicates hyperactivity of the amygdala when the patient is faced with neutral expressions[10], while Frick et al.’s study (2012) displays this hyperactivity when faced with positive or negative cues, but not neutral ones[9].

Unstable Interpersonal Relationships

Comparing Oxytocin Responses of Healthy Controls and Borderline Personality Subject
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Adapted from Bartz et al.(2011)[16] Graphic representation of cooperative behaviour of healthy controls and borderline individuals (BPD)
after an intranasal exposure to oxytocin, or a placebo. Larger numbers represent more cooperation, and less deflection.

One of the trademark symptoms of borderline personality is the inability to maintain interpersonal relationships, ranging from professional relationship to romantic ones. This is a symptom which does not improve with time and is affected by various factors. For instance, borderline subjects who have a history of childhood trauma are more likely to judge faces as unapproachable and untrustworthy[11], deeming neutral situations as a threatening and dangerous [11]. Therefore, due to the lack of cooperation unstable relationships are formed. A study by Bartz et al. (2011) shows the contrasting result of intranasally exposing borderline subject to oxytocin[12]. Oxytocin is a hormone implicated in building relationships with others, by encouraging trusting behaviour[12], however, it produces the opposite effect in borderline individuals[12]. In Bartz et al’s (2011) study, borderline participants were asked to play a dilemma game, similar to prisoner's dilemma, following intranasal exposure to oxytocin. Their results concluded that borderline patients deflect, even when they are aware ahead of time that their partner is going to cooperate[12]. The intention behind this cannot be reasoned as self-protective, since their partner’s choice has been revealed ahead of time[12]. Instead, it is interpreted as an interpersonal motive to harm their partner[12].
This irregularity might be occurring because oxytocin might be increasing the desire of borderline subjects to associate with others[12]. However, these may be a reminder for failed relationships in the past and increase concerns regarding trusting and being close with others[12]. Desperate attempts to avoid feelings of loneliness and abandonment are impeded by the borderline personality individuals’ strategies, which result in regular arguments and emotional unpredictability [12].
Studies on the brain have indicated possible biological reasons for the obstacles experienced by borderline individuals. Abnormal oxytocin response may be due to a dysregulated oxytocin system [12], while hesitant responses to trusting and approaching others may be due to a decrease in amygdala volume [11].

Self-Harm and Suicidal Behaviour

Predictors of Self-Harming Behaviour

Suicidal behaviours consist of generating suicidal plans, self-mutilation and suicidal attempts[13]. Engaging in self-mutilating behaviour may be a way to provoke sympathy and pity from clinicians, punish another individual or confirm a negative self-image[14], and holding strong negative beliefs about the self, affirmed with disappointment in interpersonal relationship increases risk of self-mutilation among borderline individuals. Studies have shown that predictors of self-mutilation and suicidal behaviour are largely environmental factors. Traumatizing events, such as childhood abuse and neglect and sexual and physical assault as an adult victim, as well as episodes of major depression are all predictors of suicidal behaviour[15]. Self-mutilation may be a consequence of dysphoric affects, as many borderline individuals claim to engage in self-harm in order to relieve negative feelings [15]. Gender is also a predictor for risk of suicidal behaviour: self-mutilation occurs more frequently among women with borderline personality disorder than men over the course of time[15]. Self-mutilation episodes arise following events that are considered stressors, generally involving love or marriage, or criminal and legal events[16].
Attempts of suicide are more prevalent in borderline patients with a low socioeconomic status, low educational levels and poor family relations[16]. Suicidal attempts and completion may occur after years of illness, where treatment has failed and supportive relationships are not present[16] but this kind of behaviour can be avoided when the patient feels supported by their family[16].

Affected Brain Structures

The fusiform, lingual and parahippocampal gyrii are the key impaired structures in suicidal borderline individuals[16]. The fusiform and parahippocampal gyrii are involved in recognizing emotional cues in facial expressions, while the parahippocampal gyrus recalls information about familiar scenes, identifies sarcasm as well as positive autobiographical information about the self[16]. In healthy individuals, these regions work together in a situation of emotional crisis, and the associative memory allows the individual to foresee positive outcomes based on previous experiences[16]. However, these structures are impaired in borderline patients due to the decrease in gray matter as well as volume, which has been correlated to violent behaviour[16].

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