This document provides information on the etiology and causes of borderline personality disorder (BPD). It discusses biological, psychosocial, and genetic factors that may contribute to BPD based on various studies and theories. Biologically, it is proposed that abnormalities in brain regions involved in emotional regulation like the limbic system, orbital prefrontal cortex, and orbitofrontal cortex may underlie BPD. Psychosocially, childhood trauma especially abuse is a significant risk factor, as are unstable family environments and attachment issues. A diathesis-stress model is discussed where biological and environmental factors interact.

1. Aetiology of Borderline
Personality Disorder
Drs. Afsa Shafi and Mohammed
Hakim

2. What is Personality Disorder
ICD – 10
A severe disturbance in the characterological condition and
behavioural tendencies of the individual, usually involving
several areas of the personality, and nearly always associated
with considerable personal and social disruption .
DSM IV
An enduring pattern of inner experience and behaviour that
deviates markedly from the expectations of the individual’s
culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over time, and leads
to distress or impairment.

3. Cluster A , B and C
• Cluster A: Odd or Eccentric Behaviors
• Schizoid PD
• Paranoid PD
• Schizotypal PD

4. Cluster A , B and C
• Cluster B : Dramatic, Emotional, or Erratic
Behaviour
eg : BPD,
Histrionic PD
Narcissistic PD
Anti-social PD

5. Cluster A , B and C
• Cluster C : Anxious, Fearful Behaviour
• Eg : Avoidant PD
• Dependent PD
• Obsessive Compulsive PD

6. ICD - 10
A . General Criteria for the Personality Disorder
must be met.
B. At least 3 from criteria B
1. Disturbances in and uncertainty about self-
image, aims and internal preferences (
including sexual)
2. Liability to become involved in intense and
unstable relationships often leading to
emotional crisis

7. ICD -10
• Excessive efforts to avoid abandonment
• Recurrent threats of acts of self harm
• Chronic feelings of emptiness

8. Epidemiology of Personality Disorders
• Prevalence of 10‐13% of adult population
• Commoner in younger age groups (25‐44)
• Overall gender ratio 1:1 but varies with individual
PD (eg. Antisocial more common in males and
Borderline more common in females)
• More common diagnosis in white than black
people
• Very common in prisons (up to 78%) particularly
antisocial

9. Epidemiology of Personality Disorders
• Prevalence in psychiatric hospital populations 36‐67%
• Prevalence increases with intensity of psychiatric care
• Cluster B (borderline, antisocial, narcissistic, histrionic) attract most
attention -
• PD prevalent in inpatients with drug, alcohol and eating disorders
• Comorbid psychiatric illness common, especially depression, and
comorbid PD can complicate recovery in severe mental illness
• Borderline 0.2% to 1.8% of general population (Community
0.7%, Mental Health OPD 8‐11%, Mental Health Inpatient
14‐ 20%), commoner in women

10. Impact of PD
• On patient (social and occupational functioning,
parenting,
• substance misuse, self‐harm and suicide
attempts, criminality)
• On family/carers
• On society (cost of use of emergency services,
• inpatient/residential/secure provision, incapacity
and other benefits, criminality)
• Suicide and premature death ( 5 % all PD’s )

11. What causes BPD
• Exact cause for BPD is not yet understood
• Seems to be a Bio- Psychosocial picture to it.
• Let’s look at each in turn.

12. Biological
• Twin studies support genetic component:
aggressive antisocial behaviour > non-
aggressive.

13. Biological
• Three different theories
– Limbic system: involved in many of our emotions
and motivations, particularly those that are
related to survival. Such emotions include fear,
anger and pleasure
– Frontal lobe (important in affective
responsiveness, social and personality
development and self awareness)
• Orbital prefrontal cortex
• Orbitofrontal cortex

14. Biological
• Three different theories
– Limbic system
– Orbital prefrontal cortex
– Orbitofrontal cortex

15. Biological
• The Limbic system
– Most primitive part of human brain
– Controls emotions
– Specially amygdala and hippocampus in charge of fear,
rage and automatic reactions
– Both significantly smaller than normal in BPD cases
– ?explanation for:
• Excess anger
• Fear in relationships
• Self mutilation

16. Biological
• The orbital prefrontal cortex (OPFC)
– Important role in inhibiting limbic regions involved
in control of generating aggression)
– Serotonin controls OPFC activity. If low, means
increased limbic inhibition.
– Also low glucose in this area leading to low
serotonin proposed as a causing factor

17. Biological
• Orbitofrontal cortex
BPD Lesions in Lesions in PFC Normal
OFC but not OFC adults
• Performance and reactions compared with tests
and questionnaires
• First two groups most similar: most impulsive,
more aggressive and less happy but not identical.
• But BPD cases more neurotic, less extraverted
and less conscientious than the rest.
• Not all traits = same cause

18. Aeitiology - Biological
• The prefrontal cortex (P.F.C.) is the anterior part of the frontal lobes of the
brain, lying in front of the motor and premotor areas.
• This brain region has been implicated in planning complex cognitive
behavior, personality expression, decision making and moderating social
behavior.[1] The basic activity of this brain region is considered to be
orchestration of thoughts and actions in accordance with internal
goals.[2]
• The most typical psychological term for functions carried out by the
prefrontal cortex area is executive function. Executive function relates to
abilities to differentiate among conflicting thoughts, determine good and
bad, better and best, same and different, future consequences of current
activities, working toward a defined goal, prediction of outcomes,
expectation based on actions, and social "control" (the ability to suppress
urges that, if not suppressed, could lead to socially unacceptable
outcomes).

19. Aetiology- Psychosocial factors
• 87% victim of childhood abuse
– 40-71% sexual abuse
– 25-70% physical abuse
• Leads to confusion
– What’s happening??? Affects thoughts and feelings
– Affects future relationships as discussed earlier
because doesn’t understand the feelings of others
– Dissociated state: emotionless during time of painful
experience of abuse and then causing self harm in
later life.

20. Aetiology- Psychosocial factors
• Theories:
• Failures of early mothering, especially mirroring
• Fear of abandonment
• High rates of parental loss
• Family history of mood disorders and substance
use
• Excessive early aggression (due to constitutional
orenvironmental factors) leading to difficulty
integrating positive and negative aspects of self
and mother and associated affects

21. Aetiology -Psychosocial factors
• Conflictual relationships with parents with
hostility,devaluation or abuse – less caring and
more controlling
• Childhood trauma, particularly sexual abuse
• Childhood trauma as risk factor for adverse
brain development – maltreated children and
adolescents havesmaller intracranial volumes,
cerebral volumes and larger lateral ventricles.

22. Aetiology -Psychosocial factors
• Importance of attachment difficulties where
early experience with the caregiver serves to
organize later attachment relationships –
‘attachment propels cognitive development’
• BPD can be understood as impairment of
capacity for emotion regulation, attentional
control and mentalization.

24. Diathesis-stress model
• Discussion:
– What comes first????

25. Discussion
• Open for your opinions
• PS: check out www.fixthelikes.blogspot.com
• The presentation is on there.