Borderline personality disorder (BPD) is a complex and severe mental illness that is characterized by poor interpersonal relationships, mood instability, and unstable self-image and behavior. Personality disorders usually begin early in childhood or the teenage years and are often ingrained in early adulthood, making these disorders very difficult to treat. Borderline personality disorder is the most prevalent and the most serious out of all the personality disorders as it is commonly associated with self-harm behavior and often co-occurs with other impulsive disorders such as eating disorders and substance abuse disorder. When borderline personality exists with another mental health disorder such as substance abuse disorder, this is known as a co-occurring disorder. A recent study examined the relationship between borderline personality disorder and substance abuse disorder and found that impulsive behaviors are increased in both of these disorders.
Impulsivity is defined as behavior without adequate thought, the tendency to act with less forethought than do most individuals of equal ability and knowledge, or a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions. Impulsive actions and thoughts can result in illegal behavior, physical harm, broken relationships and mental health disorders such as eating disorders, substance abuse, ADHD, obsessive-compulsive disorders, mania, and borderline personality disorder. Impulsivity has been linked to a surge in dopamine, the neurotransmitter that plays a major role in the addiction pathway. Addiction not only refers to drugs and alcohol but also refers to behaviors such as compulsive shopping and gambling and binge eating and many research studies have found that certain brain regions are responsible for impulsive behaviors and addiction, alike. Specifically, the anterior cingulate and the middle frontal gyrus are known to play a role in regulating emotion and behavior and studies have shown that a thinner cortex surrounding these regions may be responsible for developing impulsive decisions and actions. Similarly, research suggests that impulsivity among teenagers may be caused by a mismatch of the maturation phases in various parts of the brain particularly the frontal lobe, with regions associated with reward and thrill-seeking dominating decision-making processes.
Diagnostic criteria for borderline personality disorder
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), five of the following criteria must be met in order for an individual to be diagnosed with borderline personality disorder (BPD):
- Frantic efforts to avoid real or imagined abandonment; this does not include suicidal or self-mutilating behavior covered in criterion 5
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- Affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, or recurrent physical fights
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Substance abuse disorders and impulsive behavior
According to statistics, 22 million Americans 12 years of age and older are diagnosed with a substance abuse disorder each year and 80% of these disorders are associated with alcohol abuse. Substance abuse, addiction, and dependence is triggered by physiological and mental cravings due to a need for a dopamine rush and as a result, this craving results in impulsive behaviors in order to seek out drugs. Binge drinking and injecting heroin are generally not preconceived events but rather unhealthy coping mechanisms characterized by impulsive behaviors in order to overcome underlying life struggles.
Treatment for borderline personality disorder and co-occurring disorders
Borderline personality disorder is very difficult to treat and a combination of psychotherapy approaches and medication management is often used to help control the anxiety, depression, and transient psychosis associated with borderline personality disorder. Individuals with BPD tends to be impulsive and therefore frequently overdose on medications and therefore antidepressants and mood stabilizers must be monitored and prescribed with caution. Additionally, individuals with borderline personality disorder often have boundary issues and try to push the envelope with their treatment team by being seductive and making false allegations and therefore strict boundaries must be determined during the initial treatment assessment.