A person with borderline personality disorder may experience intense bouts of anger, depression, or anxiety that may last only hours or, at most, a few days. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in thoughts and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, identity, and values. Sometimes people with BPD view themselves as fundamentally bad or unworthy. They may feel bored, empty, or unfairly misunderstood or mistreated, and they have little idea who they are. Such symptoms are most acute when people with BPD feel isolated or lacking in social support, and they may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes toward family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize another person, but when a slight separation or conflict occurs, switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.
Most people can tolerate the ambivalence of experiencing two contradictory states at one time. People with BPD, however, must shift back and forth between good and bad states. If they are in a bad state, for example, they have no awareness of the good state.
Individuals with BPD are highly sensitive to rejection, reacting with anger and distress to mild separations. Even a vacation, a business trip, or a sudden change in plans can spur negative thoughts. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating, and risky sex. BPD often occurs with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Neuroscience is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The brain’s amygdala, a small almond-shaped structure, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal, which may be more pronounced under the influence of stress or drugs like alcohol. Areas in the front of the brain (prefrontal area) act to dampen the activity of this circuit. Recent brain-imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.
Serotonin, norepinephrine, and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much as people manage susceptibility to diabetes or high blood pressure.
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