Borderline personality disorder

Clinical picture (children and adolescents)

• The diagnosis can be made in adolescence; symptoms emerge during this period and early intervention is recommended. Prevalence in adults is about 1–3%. B
• Subthreshold borderline symptoms in adolescence predict difficulties in functioning over the following 20 years (Winograd et al., 2008; community sample). C
• Self-harm and suicidal behavior are major risks. A

Circuits and networks

• Amygdala: overreacts to negative emotional stimuli; gray matter volume smaller (Schulze et al., 2016; 19 functional studies, 281 patients). B
• Dorsolateral Prefrontal Cortex: blunted response during negative emotions (Schulze et al., 2016). B
• Anterior Cingulate Cortex (especially subgenual) and Insula: emotional pain and bodily sensation. B
• Posterior Cingulate & Precuneus: increased activity (Schulze et al., 2016). B
• Orbitofrontal Cortex and Medial & Frontopolar Prefrontal Cortex: impulse control and emotion regulation. B
• Temporoparietal Junction and Medial & Frontopolar Prefrontal Cortex: mentalizing (understanding others' and one's own mind); the target of mentalization-based treatment. C

Neurotransmitter systems

• A link between serotonin and impulsivity has been reported; there is no approved medication for borderline disorder. B
• The opioid system and the social pain hypothesis. C

Imaging and neurobiological findings

• Multimodal meta-analysis: the left amygdala is both functionally overactive and smaller in gray matter volume; amygdala hyperactivity is clear in unmedicated samples (Schulze et al., 2016). Findings are inconsistent across studies. B

Developmental course

• Early childhood trauma and difficulties in the relationship with caregivers are risk factors; symptoms may decrease over time. B

Treatment and the systems it targets

• Psychotherapy is the main treatment: dialectical behavior therapy (DBT) is the most studied, followed by mentalization-based treatment (MBT). A
• DBT for adolescents (DBT-A): in 12–18-year-olds with repeated self-harm, a clear reduction in suicidal ideation and depression compared with enhanced usual care; the advantage in self-harm frequency lasted through 3-year follow-up (Mehlum et al., 2014; 2019). B
• Medication is not recommended for borderline disorder itself; it is used for co-occurring conditions. B

Link to the book (The Green Walnut on the Couch)

• In the book (translated from the Turkish original):
  • OFC and vmPFC, clinical: "OCD, borderline and narcissistic organization, decision making".
  • ACC, clinical: "Social pain, grief, error monitoring in OCD".

In the atlas

Regions

Core structures in bold.

Networks

Neurotransmitter pathways

Panksepp systems

References

1. Winograd G, Cohen P, Chen H (2008). Adolescent borderline symptoms in the community: prognosis for functioning over 20 years. Journal of Child Psychology and Psychiatry, 49(9), 933–941. Search PubMed
2. Mehlum L et al. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. JAACAP, 53(10), 1082–1091. Search PubMed
3. Mehlum L et al. (2019). Long term effectiveness of dialectical behavior therapy versus enhanced usual care for adolescents with self-harming and suicidal behavior. Journal of Child Psychology and Psychiatry, 60(10), 1112–1122. Search PubMed
4. Schulze L, Schmahl C, Niedtfeld I (2016). Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal meta-analysis. Biological Psychiatry, 79(2), 97–106. Search PubMed
5. NICE CG78 (2009). Borderline personality disorder: recognition and management. Search PubMed