Borderline personality disorder is a serious personality disorder, which is in a critical state between neurosis and psychosis, and is characterized by capricious mood and unstable behavior.
brief introduction
1938 A Stern used the term "boundary" for the first time in the treatment of schizophrenia. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by American Psychiatric Association, borderline personality disorder must have at least five of the following eight characteristics: 1) the possibility of impulsive self-harm, such as wasting money, gambling or self-harm; 2) The interpersonal relationship is unstable or too tense, belittling others, and often taking advantage of others for their own self-interest; 3) Improper anger or lack of anger control; 4) The obstacle of identity is that gender identity, self-identity and career choice are changeable; 5) Emotional instability, such as sudden depression and anxiety, is stimulated for several hours or days, and then turns to normal; 6) I can't stand loneliness, and I feel depressed when I am lonely; 7) Self-destructive behaviors, such as self-destruction, repeated accidents or fighting; 8) Whether the test of feeling empty and tired for a long time is replaced by the psychological test below BPD can help to evaluate whether you have some factors that may lead to BPD. Answering the following questions honestly can help you judge whether you need to consult a psychologist. 1. Parents (lovers, children, friends) often feel abandoned because of their words and deeds. 2. Try not to be abandoned by others, even at the expense of madness (such as crying and self-abuse). The friends I met at first are simple, but after a long time, I feel that they can't accept me. I often feel unbearable loneliness. 5. Emotions are extremely volatile, and stable emotions will not last for several hours. 6. Unable to control anger, it is easy to have disputes or physical conflicts with others. 7. Repeatedly use self-harm behavior to get relief or pleasure. 8. Often threaten suicide or ask for help. 9. At least two definitions of self-image, gender orientation, long-term goal or career choice, friends who like to associate, and value preference are not clear. 10. I feel empty and bored for a long time. 1 1. Feel inferior and often feel disappointed, helpless and powerless. 12. It is often contradictory and pessimistic about new things. 13. Stubborn. 14. Arrogance. 15. It is difficult to communicate with authoritative people. 16. Too sensitive to criticism, easy to feel despised and ignored. 17. Have a history of pleasing others. 18. Blame yourself. 19. Excessive vigilance and sensitivity to surrounding unsafe factors. 20. It is easy to produce unreasonable fear and confusion. Evaluation criteria: the above 20 topics, 1 ~ 10, are the general characteristics of borderline personality disorder; 1 1 ~ 15 is entitled subtype characteristics of willful borderline personality disorder; 16 ~ 20 is entitled subtype characteristics of self-destructive borderline personality disorder. If there is a "yes" answer, you should worry about yourself. If there are two "yes" answers, it is recommended to consult a psychologist immediately. Clinical manifestations and diagnosis of borderline personality disorder Borderline personality disorder is a common personality disorder in psychiatry, which is characterized by unstable emotions, interpersonal relationships and self-image, accompanied by a variety of impulsive behaviors, and is a complex and serious mental disorder. The typical characteristics of borderline personality disorder are described by scholars as "stable and unstable", which is often characterized by non-compliance in treatment and is very difficult to treat. The diagnostic entity of borderline personality disorder began to enter the psychiatric diagnosis, which is DSM-I of 1948. At that time, its name was "Emotional Unstable Personality Disorder", and 1968 was cancelled in DSM-II because it overlapped with another diagnosis-circulatory personality disorder. DSM-III was launched on 1980. Until now, the diagnosis of DSM-IV-TR borderline personality disorder has been retained, replacing the circulatory personality disorder. Borderline personality disorder has experienced a long history from discovery to clinical diagnosis. This can be traced back to Pinel's observation in 180 1. He found that some mental patients remained rational. 1837 prichard pointed out that many people who are considered to be "crazy for no reason" actually have mental illness, but this mental illness is mainly reflected in different emotions, habits and temperament. Many of the patients they observed are actually what we call borderline personality disorder today. 1890, American Rosse first used the word "edge" to describe a group of patients between neurosis and psychosis. In 1907, Kraepelin describes the marginal state, which is related to the morbid personality inferiority complex. In 1909- 19 19, Paellmann and Clark also discussed the relationship among borderline mental state, borderline neurosis and psychosis respectively. In 192 1, Kraepelin proposed that boundary type is a vast but uncharacteristic field, and this state is between madness and various bizarre manifestations of normal people. In 1928, Reich emphasized that people with personality disorder, especially those with impulsive personality, are marginal patients. 1930, Partridge studied antisocial personality in Inferiority of Physically Sick Personality, and proposed to exclude this diagnosis. In the same year, Oberndorf, an American, noticed that many psychiatrists in the United States were using psychoanalytic theory to study and treat borderline mental patients, but this tendency was actually different from the international mainstream at that time. 1938- 1957, psychoanalyst stern studied and treated many borderline patients, and began to describe and summarize the symptoms of borderline personality. In 1942, psychoanalyst deutsch described "specious personality", which is actually the borderline personality today. In 1949, Hoch and Polatin described a group of patients with "pseudoneurotic schizophrenia", and later Schmideberg named them "borderline". From 65438 to 0954, Knight used psychoanalytic self-psychology and object relationship theory to describe, analyze and treat marginal patients. In 1955, Glover also pointed out that personality disorder is a marginal state. During this period, American psychiatrists have been at the forefront of studying marginal patients all over the world, and they mainly study these cases from the perspective of psychoanalysis. From the late 1950s to the mid-1970s, the research on marginal state began to be carried out on a large scale, and many cases were accumulated. Psychoanalyst Kernberg summed up the research results in psychoanalysis, put forward the term "borderline personality organization" and expounded its diagnostic points. Gundersen and others further sorted out these descriptive case experience works in psychoanalysis and transformed them into operational definitions. The diagnostic criteria of DSM-III are basically carried out according to their working framework. Since 1980s, the research on borderline personality disorder has developed rapidly. The research on epidemiology, etiology, diagnosis and treatment of borderline personality disorder has emerged one after another, and has become one of the mainstream research topics in the field of international psychiatry, which goes hand in hand with the research on schizophrenia, mood disorder and post-traumatic stress disorder. The clinical manifestations of patients with borderline personality disorder mainly include the following symptoms. First, the disorder of self-identity. Lack of self-goal and sense of self-worth, inferiority, for such things as "who am I?" "What kind of person am I?" "Where am I going?" This kind of question lacks thinking and answers. This disorder of self-identity often begins in adolescence, while patients with borderline personality disorder obviously lag behind in self-identity and stay in a chaotic stage for a long time, and their self-image is discontinuous and contradictory. This is reflected in various contradictions and conflicts in their lives. Second, an unstable and rapidly changing mentality. Patients often have strong anxiety, and easily swing between anger, sadness, shame, panic, fear, excitement and omnipotence. Often surrounded by long-term, chronic and diffuse emptiness and loneliness. Mentality is characterized by rapid change. Especially in stress events, patients are prone to short-term nervousness, irritability, panic, despair and anger. However, their emotions often lack the lasting sadness, guilt and infectivity that are unique to depression, and there are no biological characteristics such as waking up early and wasting. Third, significant separation anxiety. They are described as "walking into life with umbilical cord in their hands, always looking for a place to pick it up". Very afraid of loneliness, afraid of being abandoned Extremely sensitive to abandonment and separation, do everything possible to avoid separation scenes, such as begging or even suicide threats. They are very afraid of loneliness and lack the ability to comfort themselves. They often need to dispel their inner emptiness and loneliness through various stimulating behaviors and substances such as drinking, promiscuity and drug abuse. Fourth, the intimate relationship of conflict. They will swing between the two extremes in intimate relationships. On the one hand, we are very dependent on each other, on the other hand, we always quarrel with people close to us. One minute I think the other person is the best in the world, and the next I say the other person is worthless. Repeated relationship breakdowns and conflicts in interpersonal relationships. People who get along with them often feel tired, but they can't get out. Fifth, impulse. Common impulsive behaviors include alcoholism, profligacy, gambling, theft, drug abuse, gluttony and fornication. 50% ~ 70% patients have impulsive self-destruction and suicide behavior, and 8 ~ 10% patients succeed in suicide. This is a disease with a high suicide rate. Sudden rage, beating, smashing and looting, fighting and swearing are also common impulsive behaviors. Sixth, symptoms of mental stress. Under pressure, personality disintegration is easy to occur, involving ideas, such as short-lived or situational hallucinations or hallucinations that seem to have a realistic basis. Generally speaking, these symptoms are mild and short-lasting, and can be quickly relieved after mental stress is relieved, and antipsychotic drugs are also effective. The most authoritative diagnostic standard of borderline personality disorder is DSM-IV (American Diagnostic and Statistical Manual of Mental Disorders, 4th Edition). This diagnostic criterion originated from 1967. Based on the work of psychoanalysts Stern and Knight, Kernberg put forward the concept of borderline personality organization (BPO). Borderline personality structure includes many serious personality disorders, which are: 1) identity diffusion; 2) Primitive defense mechanisms, such as division, idealization, denial, projection, action and identity projection; 3) Generally speaking, the ability to test reality is good, but it is hard to bear changes and failures. On this basis, 1975, Gundersen &; Singer reviewed the previous research on clinical observation of borderline personality, and put forward several descriptive criteria, including irritability, impulsive behavior, poor interpersonal relationship, psychotic cognition and social maladjustment. And developed a semi-structured research tool DIB (Boundary Diagnosis Interview). 1978, Gundersen &; Kolb et al. made a statistical study on 33 patients with borderline personality by DIB, and determined 7 diagnostic criteria. 1979, Spitzer, Kernberg, Grinker and others further studied large samples and determined eight diagnostic criteria of DSM-III BPD. By 1994, the diagnostic criteria of DSM-III have been studied for more than 300 times, and finally nine diagnostic criteria of BPD have been determined. A behavior pattern characterized by interpersonal relationship, self-image and emotional instability and obvious impulsiveness, which began in early adulthood and appeared in various situations, has at least the following five items: 1. Crazy efforts to avoid real or imagined abandonment (excluding suicide or self-harm in item 5). 2. An unstable and tense interpersonal relationship model, which is characterized by two extremes: idealization and debasement. 3. Identity obstacle: obvious and lasting instability of self-image or self-awareness. (Note: The uncertainty of normal adolescence is not included. 4. Impulse in at least two potentially harmful aspects (such as spending money, sex, substance abuse, reckless driving and overeating). (excluding suicide or self-injury in item 5) 5. Repeated suicidal behavior, suicidal posture or suicidal threat, or self-injury behavior. 6. The obvious emotional response causes emotional instability (for example, severe paroxysmal irritability, irritability or anxiety, which usually lasts for several hours and rarely exceeds a few days). 7. Long-term emptiness. Improper strong anger, or uncontrollable anger (such as frequent tantrums, persistent anger, repeated fights) 9. Short-term stress-related paranoia or severe symptoms of separation. Because there are many diagnostic tools to diagnose borderline personality disorder, in addition to DIB mentioned above, there is also DIP DIV(DSM-IV Personality Disorder Diagnosis Interview). IPDE (International Personality Disorder Examination), SIDP-IV(DSM-IV Personality Structured Interview), Pdi-iv (Personality Disorder Interview -IV), scid-ii(DSM-IV Axis ii Personality Disorder Structured Clinical Interview), etc. SCID-II and DIB-R are the most widely used tools in clinical research, and they have been translated into Chinese. In addition, the former has been tested for reliability and validity. The prevalence rate of borderline personality disorder in the United States is 1-2%, which is as much as 8%. It accounts for 10% of psychiatric outpatients and 20-25% of inpatients. There are more women than men, and the ratio of male to female is 1: 3. About 70% are women and 30% are men. Among the patients diagnosed with personality disorder, the proportion is 30 ~ 60%. About 10% patients will commit suicide, which is 50 times that of the general population. According to the community survey, the prevalence rate of BPD is as high as 1 1% in the population aged 9-1-21year, and the prevalence rate is as high as 7.8% in the population aged 9-1%,with more girls than boys. An epidemiological survey in Norway shows that the prevalence of adult borderline personality disorder is 0.7%. The incidence of borderline personality disorder is extremely prominent. Please refer to other chapters of this article for its * * * incidence and other epidemiological research results. Etiology and Pathology There have been different views on the etiology and pathology of borderline personality disorder, and the research results mainly focus on the following aspects. First, heredity has always been assumed by scholars that borderline personality disorder is closely related to heredity. However, there is little research on its heredity. Nine studies have found that relatives of borderline personality disorder, especially first-degree relatives, have a high prevalence of this disease, but unfortunately, only two of them can stand the scrutiny of statistical data. Torgerson( 1984.2000) and others have done some research on identical twins and fraternal twins with borderline personality disorder. Early small sample research found that the role of environment in the formation of borderline personality was greater than that of heredity, but in 2000, a large sample study got another result, the value of genetic effect was close to 0 .70, and the general family environment had little influence. Secondly, neurobiology uses brain imaging technology to find that the brain structure of patients with borderline personality disorder has changed. Some found that the frontal lobe volume decreased (Lyoo, 1998), while others found that the hippocampus and amygdala volume decreased (Driessen, 2000; Brenner JD, 1997, Christian G, Schmahl, 2003) The research results of brain functional imaging are also varied. Herpertz SC et al (200 1) found that amygdala, fusiform gyrus and anterior cingulate gyrus were active in patients with borderline personality. Nelson H. Donegan(2003) also found that the activity of the left amygdala in patients with borderline personality was significantly enhanced. Tebartz van Elst L(200 1) found that the neurological function of the posterior prefrontal cortex and the left striatum in patients with borderline personality disorder was impaired. Soloff et al. (2003) found that the central frontal gyrus, dorsolateral prefrontal cortex and prefrontal-orbital cortex of borderline personality disorder were in a state of low metabolism. Soloff PH et al. (2000) and Siever et al. (1999) found that the low metabolic state of the prefrontal lobe was related to the weakening of serotonin function. A large number of neurobiochemical studies generally support the view of Leyton et al. (200 1) that the decrease of serotonin synthesis ability in cerebral cortex pathway may lead to the increase of impulsiveness in patients with borderline personality disorder. Generally speaking, the hypothesis of neurobiology is that traumatic experience, parent-child interaction disorder and other early stress conditions can lead to the impairment of neurological functions related to emotional regulation in children at the critical stage of brain development. Long-term stress increases the level of glucocorticoid, reduces the neurotrophic factors produced by the brain, and inhibits neurotransmitters, thus causing changes in the volume of hippocampus and amygdala and a decrease in serotonin content. Changes in brain function and structure will make individuals more prone to borderline personality disorder. However, there is a problem with the above theoretical hypothesis, that is, this theoretical model is actually very similar to the theoretical model of post-traumatic stress disorder, that is, does this theory explain the pathogenesis of borderline personality disorder or the pathology of post-traumatic stress disorder often complicated with borderline personality disorder? The relationship between post-traumatic stress disorder and borderline personality disorder is also a problem worthy of discussion. Thirdly, there are many psychopathological hypotheses about borderline personality disorder. Generally speaking, there are two main psychopathological hypotheses: 1) defect-conflict model. This is mainly put forward by psychoanalysts. According to this view, the psychopathology of borderline personality disorder comes from the lack of many external environments in the early stage, especially during the separation of infants and caregivers. Such as improper punishment of caregivers, replacing adults with babies to meet the wishes of babies, family trauma, mother's mental quality and so on. Such an unqualified environment is likely to cause defects or abnormal development of the baby's self-development. Such a child with self-defects will encounter many conflicts, especially the conflict between dependence on the object and fear in the separation scene. It is embodied in children's disintegration dependence or anxiety/conflict subtype dependence and transitional object-related dependence. In order to adapt to these psychological difficulties, children will use primitive defense mechanisms (splitting, projecting identity, etc.). ) to adapt to life. These defense mechanisms further strengthen the marginal pathology. Such children rarely get through the psychological crisis of adolescence. So as to grow into a borderline personality disorder patient in adulthood. Many studies have proved the above hypothesis. For example, seven studies have proved that people with borderline personality disorder have extremely insecure attachments. Some psychological studies using Rorschach test have also confirmed that people with borderline personality disorder have the characteristics of degeneration of appetite. Perry and Cooper (1986) found that split and projected identity were more related to BPD patients than antisocial personality disorder and bipolar II patients. Bond (DSQ), the inventor of the Defense Mechanism Scale, also proved (Bond et al., 1994) that patients with borderline personality disorder use more defense methods such as splitting and putting into action than other mental patients. 2) The cognitive school of cognitive-schema deviation also admits that there is a traumatic environment in the early childhood of patients with borderline personality. However, scholars of cognitive school tend to think that it is not stress events themselves that lead to borderline personality disorder. However, after the traumatic event, many factors, such as children's coping style, individual temperament, age, situation, naive coping style and the strengthening of negative reaction of educators, determine the borderline pathology, which is concentrated in the patient's core schema and core cognition. The typical cognitive biases of patients with borderline personality disorder are catastrophe and dichotomy thinking, and their core beliefs have three themes: first, the world is evil and my life is dangerous; Second, I am like a child, I am weak and fragile; Third, I was forgotten. I was born without anyone. People with borderline personality disorder have five core schemata: abandoned children, angry/impulsive children, punitive parents, separated protectors and healthy adults. Generally speaking, the etiology and pathology of borderline personality disorder are still unclear, and the existing assumptions often lack strict evidence and specificity. For example, the theoretical hypothesis of psychopathology can be used to explain not only borderline personality disorder, but also most personality disorders. At present, the treatment modes of borderline personality disorder are mainly drug therapy and psychotherapy. Because there is no comprehensive, effective and targeted drug to treat borderline personality disorder, psychotherapy has been widely concerned by psychiatrists. First, psychotherapy At present, there are more than a dozen psychotherapy models for borderline personality disorder. Among them, the only one supported by the most evidence-based medical evidence is dialectical behavior therapy (DBT). Although RCT(random control trial) of dialectical behavior therapy is still insufficient in epidemiological methods, it is still the first choice for borderline personality disorder from the perspective of evidence-based medicine. Another therapy supported by RCT trial is the partial hospitalization of Bateman and Fonagy, which is a comprehensive and systematic treatment system, similar to DBT, and its core individualized treatment is dynamic, which is called mentalization-based therapy (MBT). However, only one RCT study supports the efficacy of MBT. Baker's cognitive therapy, schema therapy, Stevenson's and Mills' modern self-psychotherapy have all been clinically tested and proved to be effective, but none of them meet the requirements of RCT. Transfer focused psychotherapy (TFP) is undergoing RCT, and the pre-trial effect is good. The official RCT report has not yet been published. Two studies have proved the efficacy of group therapy for patients with borderline personality disorder. However, these two studies have problems in setting up the control group. Other psychotherapy techniques commonly used in clinic, such as relationship management psychotherapy, structured assessment of social behavior, self-management therapy and family psychological education in Gundersen, lack evidence-based medical evidence. Perrry and others summarized the curative effects of various treatment methods for personality disorder and used meta-analysis. The result is that psychotherapy is really effective for personality disorder. However, many studies in this meta-analysis are not RCT. Second, drug therapy drug therapy research still has the same problem: lack of high-quality RCT research. Mainly traditional "clinical research". Three studies have found that olanzapine has an effect on the impulsiveness of borderline personality. Studies by Coccaro( 1997) and Thomas(2002) show that serotonin reuptake inhibitors (SSRI) such as fluoxetine and sertraline can effectively control emotional disorders and impulsive behaviors, such as rapidly changing emotions, anger, impulsive attacks and self-injury. The dose is equivalent to the dose for treating depression. However, too high dose of SSRI will increase the self-injury behavior of patients. Monoamine oxidase inhibitor (MAOI) is also used to control emotional symptoms, hostility and impulsive behavior caused by emotional instability. At present, few clinicians use tricyclic antidepressants to treat patients with borderline personality disorder. Caudry (1988) found that these drugs seem to increase patients' suicide and behavior out of control, but in fact, there is not enough evidence to prove whether tricyclic antidepressants are effective. Similarly, the efficacy of mood stabilizers widely used in clinic is also lack of evidence. Only one RCT verified the curative effect of lithium carbonate on borderline personality disorder, and the result was invalid. Studies by Stein( 1995) and Holland (200 1) have proved that emotional stabilizers such as sodium valproate and carbamazepine and antiepileptic drugs can effectively control impulsive behavior, and may also have the effect of regulating emotions. A recent study by RCT proved that lamotrigine is effective in controlling impulsive behavior. To sum up, although there are many studies on the etiology, pathology and diagnosis of borderline personality disorder, there are still few studies on therapeutics, especially high-quality RCT studies. This is in sharp contrast to the therapeutic research of depression, which has been proved by many RCT and high-quality meta-analysis. At the same time, it also reflects from one side that in the clinical work of psychiatry, many diagnosis and treatment methods still stay in the era of empirical medicine.
[Edit this paragraph] Etiology of borderline personality disorder
biotic factor
Genetic research shows that the onset of borderline personality disorder may be partly the result of genetic action, but the evidence is insufficient and the methods are flawed. PET (Positron Emission Tomography) also shows that subtle damage to the prefrontal cortex, which controls emotions and plans, is related to personality disorder.
Social and cultural factors
Many social factors will increase the incidence of personality disorder. Compared with the general population, patients with borderline personality disorder are more likely to be neglected by their parents, more likely to have multiple caregivers, and more likely to experience parental divorce, death or childhood trauma. These results show that the incidence of borderline personality disorder will change due to the changes of social factors that promote or hinder family intimacy. Paris pointed out that the incidence of this disease does seem to be increasing, but these results may be related to the change of diagnostic criteria, so more evidence is needed to support this model.
Psychological process
Psychological process transforms the above social factors into personal experiences. Object-relation theorists believe that the negative experiences of childhood make individuals form fragile selves, which leads them to need to confirm things repeatedly to eliminate doubts. They frequently use a defense mechanism called "split" to divide the objects into "all good" or "all bad". As a result, they cannot integrate the positive and negative aspects of themselves or others into a whole. They can't understand the contradictory elements between themselves and others, which makes it difficult for them to adjust their emotions. Sometimes they think the world is "perfect" and sometimes they think it is "extremely bad". Cognitive theorists believe that negative childhood experiences will be transformed into unsuitable schemas about self-identity and other people's relationships. These schemata include: thinking that "I am a bad boy" leads to self-punishment; That "no one will like me" leads to avoiding intimate contact; And the belief that I can't do it alone leads to excessive dependence. Self-harm can also be learned through the process of operant conditioning, such as using self-harm to intimidate and successfully control others. On the other hand, the lack of other coping resources also means that patients with borderline personality disorder will still use this strategy without any reward.
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