Let’s start with a story here... A regular guy in his 20s, medical student, friendly and approachable, basically how you’d think a guy would be like when you say a good chap. The story is about a regular day in this regular guy’s life. The kind of day most of us won’t even remember 3 days later. Now this guy is hanging out with his friends, friends he can depend on for most of his problems. One would say that’s amazing, hangouts are always fun. This is where things are irregular with our regular guy. You see what started as a happy gathering of friends ended 3 hours later with our guy on verge of a mental breakdown, tears welling up in eyes, headache throbbing with every heartbeat, breathing in getting difficult with every passing breath with Chaos inside his mind, thoughts of utter worthlessness, how he doesn’t deserve the friends he has, how he’s always been alone, how his friends don’t even try to understand his situation, how they are all bad friends.

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Read it? I know what you will say. It doesn’t make sense. I agree. For most of us, it doesn’t make sense. Now, look again at the thoughts he had. Look at the range.,Look at how extreme they were.How they changed from one pole to another.  That, my friends, is how you’ll see a patient of Borderline Personality Disorder manifesting symptoms.   

Borderline Personality Disorder or Emotionally Unstable Personality Disorder is a long-term pattern   of abnormal behaviour characterized by Unstable interpersonal relationships, Unstable sense of self and Unstable emotions. The patients often give a history of Feeling  of emptiness, tendency to self-harm and an extreme fear of abandonment, usually patients also have dangerous behaviour such as use of illicit drugs, unsafe sexual practices etc. 

Symptoms may be triggered by seemingly normal event and tend to persist for a long time. A core characteristic of BPD is affective instability, which generally manifests as unusually intense emotional responses to environmental triggers, with a slower return to a baseline emotional state. Patients with BPD tend to feel emotions deeper than others; hence they feel euphoria instead of joy but are also prone to dysphoria. Similar condition goes for Anxiety, Embarrassment and Annoyance   as well where they feel Panic, humiliation and rage respectively.

 

Impulsive behaviour is common, including substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending, and reckless driving. Impulsive behaviour may also include leaving jobs or relationships, running away, and self-injury. People with BPD act impulsively because it gives them the feeling  of  immediate relief from their emotional pain. However, in the long term, people with BPD suffer increased pain from the shame and  guilt that follow such actions. 

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Self-harming or suicidal behaviour is one of the core diagnostic criteria in the DSM-5. Self-harm occurs in 50 to 80% of people with BPD. The most frequent method of self-harm is cutting. Bruising, burning, head banging or biting are not uncommon with BPD. There is evidence that men diagnosed with BPD are approximately twice as likely to die by suicide as women diagnosed with BPD.

The lifetime risk of suicide among people with BPD is between 3% and 10%. A BPD patient’s feelings about others often shift from admiration or love to anger or dislike after a disappointment, a threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called splitting, includes a shift from idealizing others to devaluing them. Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers. Self-image can also change rapidly from healthy to unhealthy. While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or  ambivalent or fearfully preoccupied attachment patterns in relationships.  

    

Diagnosis :  

Millon’s Subtypes - Theodore Millon - Suggested that a person may exhibit none, one or more of the following:

1. Discouraged borderline : Avoidant or dependant behavior - Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless. 

2. Petulant borderline : Negativistic Feature - Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily feels "slighted" and quickly disillusioned.  

3. Impulsive borderline : Histrionic and antisocial - Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, the individual becomes agitated; gloomy and irritable; and potentially suicidal. 
4. Self-destructive : Defensive or masochistic and self-defeating - Inward-turning, self-punishing ; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.  

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Misdiagnosis :

 

It’s easy to misdiagnosis BPD as it can occur as a comorbidity in depression, PTSD, bipolar disorder.  

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Management : 

i) Psychotherapy - Dialectical Behavioral Therapy, dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), transference-focused psychotherapy, general psychiatric management,  schema-focused therapy.  
ii) Medications - Typical and atypical antipsychotics, mood stabilizers, placebo has surprisingly proved to be effective in reducing suicidal ideation.