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Notes from Professionals

Etiology of BPD

John G. Gunderson, MD

Like other major psychiatric disorders, the etiology of the borderline personality disorder (BPD) involves both genes and environment. The genetic component, which has been underappreciated, is substantial. It is not, however, the disorder itself which is inherited. Rather, what is inherited are forms of temperament that predispose a child to develop this disorder. The predisposing temperaments (aka phenotypes) for BPD are Affective Instability, Impulsivity, and Needy/Fearful Relationships.

Each of these temperaments predisposes to other disorders as well as BPD; Affective Instability also predisposes to mood disorders, Impulsivity also predisposes to substance / alcohol abuse, bulimia, and conduct disorder, and Needy/Fearful Relationships also predispose to histrionic, dependent, and avoidant personality disorders. The presence of these inherited temperaments helps explain why patients with BPD are often co-morbid with these other disorders.

Still, these predisposing temperaments do not by themselves explain the etiology of BPD. They make it possible for someone to develop this disorder.

To develop BPD also requires unfortunate environmental conditions. Most theories believe that early caretaking experiences are very important. Here, patients who have BPD will often report that their parenting was inconsistent, neglectful, or even malevolent.

This perspective is deeply distressing to parents. Some parents will feel deeply guilty as they review the past and elaborate on their failures. Others will dismiss the accusations, deny having any role, and thereby add to their borderline offspring’s alienation.

Early caretaking relationships are significantly shaped by the child.  This contrasts with the more widely recognized belief that parental interactions significantly shape the child. Thus, the easily upset, needy/fearful, hyperactive child who possesses the predisposing temperaments for BPD will pose special problems for parents. Such a child will benefit from forms of parenting that may not come natural to their parents.

The easily upset child may need an unusually calm and patient caretaker. In its absence their emotions may be poorly integrated and disturbing to them. The needy/fearful child may require a consistently involved reassuring caretaker. In its absence, their fears of abandonment may become unrealistic. An impulsive child may need parenting marked by predictability and non-punitive limit setting. In its absence, they may not develop self-controls.

Regardless of the early childcare, the child with predisposing temperaments for BPD will be far more easily undone by traumatic events. Most children with trauma grow up without sequelae. Those who suffer enduring consequences from trauma have both a predisposing temperament and -- perhaps due to problematic early caretaking -- will often have failed to disclose and process the event with their caretakers.

It is not easy to develop BPD. I expect that only a small fraction of the people who have the genetic disposition go on to develop it. Parenting is sometimes dysfunctional, but villains are truly rare. We need far more research to understand the contributions of both genes and environment.

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Families Cannot Go It Alone

Joel Paris, MD

Families have long been the mainstay for their relatives with mental illness. Families impacted by borderline personality disorder (BPD) are no exception. However, their plight is three decades behind families whose lives have been altered by other psychiatric illnesses. What was once the horror of being vilified as a schizophrenogenic mother was replaced then by being a victim, a parent with a brain disordered child. 

BPD parents are not so fortunate in that respect. Often portrayed as individuals high in affectivity, high in borderline traits, high in substance use disorders with their own suspected levels of pathology, parents of BPD sufferers are often described as perpetrators of verbal, emotional, sexual abuse, and or of neglect.

Certainly we cannot summarily dismiss all allegations and surely in some families, great injustices, to say the least, were done, in many others there is relatively little evidence of malevolence. Just as the illness of BPD is heterogeneous from many aspects, so are the families of BPD sufferers. Rather than continually pointing a finger of blame, we need to find a balance as we invite families to engage in the recovery of their relatives. Family matters!

Conversely, due to the severity, symptomatology, and high rates of co-occurring disorders, BPD not only affects the diagnosed but also affects family members and others in their social environment. Families cannot go it alone. Unfortunately, relatively few professionals have included family members in the treatment process.

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Marianne S. Goodman, M.D.

Marianne S. Goodman, M.D. is an Assistant Professor of Psychiatry at The Mount Sinai School of Medicine. She is involved in treatment research on borderline personality disorder, clinical work and coordinates the medical student education program for the department of Psychiatry at the Bronx VA Medical Center. Her research focuses on Dialectical Behavioral Therapy treatment for Borderline Personality Disorder and childhood trauma antecedents.

Recent Publications:

Goodman M, Yehuda R: The relationship between psychological trauma and borderline personality disorder. Psychiatric Annals, 32, (6): 2002, 337-346.

When I was asked by Dr. Perry Hoffman to facilitate a “break-out” lunch session at the NEA-BPD Family Perspectives Conference, I had no idea that the conference was going to catalyze and propel me on a new journey. I was looking forward to the conference because of my clinical work and research interests in the underlying neurobiology of BPD. When I arrived at the conference at 10:15 a.m. on the Saturday morning, I was overwhelmed by the size of the room and struck by the attention, concern, and focus on the faces of the conference participants. I looked around to try and find a seat, and managed to find one open space in the back of the room.

Usually at the scientific conferences I attend, the back of the auditorium houses individuals who want to sleep and escape attention. But this was not the case at the NEA-BPD conference. Everyone was listening intently, taking notes, absorbed in the words from consumers and family members discussing their personal involvement with the disorder. The woman next to me was tearful, as was a young woman in the next row. A husband leaned over and comforted his wife as she too was stirred by what was being spoken. The emotions and feeling generated in this giant ballroom were compelling and emotionally moving. I fished through my bag looking for tissues to wipe the tears forming in my eyes, realizing I had left them in the diaper bag at home.

This disorder causes tremendous strife not just to those struggling with the intolerable mood states, anger, self-hatred, and well intentioned but harming ways to help themselves, but to those who interact with, care for, and are cared by these individuals. The effects on mothers, fathers, siblings, and children are something I was intellectually aware of, but not fully appreciative of the depths and power of these effects. This was surprising to me as I have a sister with an autistic child, whose life has been turned upside down as a result. She has conducted an exhaustive search for cures, treatment programs, and strategies to help in any little way. I have watched the process of transformation in her life and development of a mission to advocacy work for her son and others who suffer with this devastating brain disorder. Her passion and determination are inspiring.

To be in a ballroom full of equally passioned and determined individuals was uplifting and energizing to me. The union of families, consumers, clinicians, researchers, and political advocates joining in the service of helping individuals with BPD offers tremendous promise and hope to a disease that some believe is “ not changeable”.

In the Breakout Session, my new journey was initiated. I found that my ability to discuss, explain, and educate about the biological basis of the disorder was extremely valued and immensely helpful to others, and that this information was previously either inaccessible or not understandable. It was relieving and destigmitizing for one young woman to consider that there may be regions of the brain where faulty wiring may be potentiating emotional reactions and that she is not just being “manipulative”. Here was an audience hungry for information but needing help with translating scientific language and findings. That science may offer possibilities of help is promising.

My colleague Antonia New and I have discussed with Perry Hoffman a mechanism to continue the process of education and translation of current scientific information to benefit consumers and families and have decided to embark on a written column titled “ The Journal “on this borderline personality disorder website. This column will provide education on various research perspectives and current developments with a focus on the implications for treatment and on achieving a better understanding of the disorder. We welcome comments and questions from our readers. Please contact us at marianne.goodman@med.va.gov and antonia.new@med.va.gov.

We look forward to hearing from you!

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Antonia S. New, MD

Antonia S. New, MD is the Associate Director of the Special Evaluation service and an Assistant Professor of Psychiatry at The Mount Sinai School of Medicine. She is involved in research, clinical work and teaching at the medical school. She specializes in borderline personality disorder, exploring the neurobiological underpinnings of this disorder as well as the implications of these findings on treatment. Her research focus is on impulsive aggression and she uses neuroimaging techniques, genetic studies, and laboratory assessment of behavior and treatment studies. She also studies the effect of sex hormones on impulsive aggressive behavior.

Recent publications:

New AS, Hazlett EA, Buchsbaum MS, Goodman M, Reynolds D, Mitropoulou V, Sprung L, Shaw RB Jr, Koenigsberg H, Platholi J, Silverman J, Siever LJ. Blunted prefrontal cortical 18fluorodeoxyglucose positron emission tomography response to meta-chlorophenylpiperazine in impulsive aggression.

Arch Gen Psychiatry. 2002 Jul;59(7):621-9.

New AS, Gelernter J, Goodman M, Mitropoulou V, Koenigsberg H, Silverman J, Siever LJ. Suicide, impulsive aggression, and HTR1B genotype. Biol Psychiatry. 2001 Jul 1;50(1):62-5.

Recently, I received a call asking me if I wanted to moderate a session on borderline personality disorder for a conference for National Education Alliance for Borderline Personality Disorder for patients, families and health professionals working with these patients. As an academic psychiatrist, I had been working on neurobiological models for this disorder for years, and yet I hesitated, wondering if I had anything to offer. My work life is spent mostly planning studies, applying for grants, analyzing data, and writing papers etc. But the reason I had chosen to study this disorder was because of an encounter I had had many years ago as a resident.

At that time, I took care of a 15-year-old girl who had a long history of cutting herself. This behavior puzzled me and I asked her why she did this. She told me that she often felt that life was unbearable, and that cutting herself was the only thing that made her feel better. I asked how she had first started, how she had thought of this. She replied that she had never known anyone who had cut themselves nor had she heard of anyone who did it. The first time she cut herself it was with the thought of suicide, but then she discovered that cutting herself lightened her dark, hopeless mood. She was the first of many borderline patients I met with similar stories. I met a patient who struggled mightily to control outbursts of rage that filled her body from head to toe tingling through her whole being. Her mother told me that she knew from an early age that something was wrong. Her little 18-month-old daughter would have such fits of temper that she actually broke her crib.

I was eager to get back in touch with the people who had inspired me to try to understand this illness in the first place, although I wondered what I really knew about the disease that might be helpful to others.

I accepted the invitation to the conference and arrived at a morning panel to hear moving stories and pleas for more research and treatment for this disorder by family members of patients with BPD. They described what it was like to have a mother, a sister, a daughter, a niece with this disorder. They described the anguish, the frustration, and also the anxiety felt on their behalf. The morning session ended and I went to “run” the Breakout Session.

At first we all sat together and ate our lunch. Everyone needed a break after the emotionally raw morning. As I stood up to try to get the group to engage in a discussion together, I asked people to introduce themselves and to explain how they happened to be at this meeting. Present were professionals treating people with BPD, parents of patients with BPD, patients themselves, sisters of BPD patients. All were there to try to understand this enigmatic disease, hungry for understanding. One mother said that her 17-year-old daughter had just been diagnosed and she wanted so much to have a clearer picture of the disorder than she had received from her daughter’s psychiatrist. Another woman wanted to know what kind of colleges might provide the best environment for a borderline person to succeed.

What followed was wonderful. One of the young women in the session acknowledged her own diagnosis of borderline personality disorder, and offered that she had just started college. She was able to share information about how she had gone about choosing her school. I was able to provide information from my work in neuroimaging to give a backdrop on which some of the symptoms of BPD are played out and provide a glimpse into the underlying neurobiology of this disorder. There was openness and willingness to share experiences and to value information that might be helpful, from whatever quarter or voice experience could provide. What I had to offer from a neurobiological vantage point seemed helpful, but I left feeling as if I had received more than I had given.

I left feeling reinvigorated from the openness of people about the suffering and the strengths of people living daily with the disorder. I was renewed in my commitment to understand and help to find better treatments; I felt I had gained an even clearer focus for my work. I had always known that it was a political risk in my career to try to tackle this disorder, but this conference renewed in my commitment to stand up and confront the terrible stigma of this disease (which is even above and beyond other mental illnesses). The diagnosis of borderline personality disorder is all too frequently used as a fancy way of insulting people and calling them a bad person. 

My commitment remains to work toward setting up a larger treatment center and getting even more research funds to understand what causes borderline personality disorder, and even more importantly, what treatment makes it better.