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The Diagnosis and Treatment for Depression Co-Occurring with Borderline Disorder

The majority of people with borderline disorder suffer from episodes of major depression. Treatment for depression is vital in these individuals. There are two categories of major depressive episodes, those associated with bipolar I and II disorder-depressed*, and those referred to as major depressive disorder. Bipolar depressions are more frequent with borderline disorder, and are commonly associated with atypical features (see below).

Therefore, if you have borderline disorder, it is important that you know and recognize the symptoms of these disorders. If they occur, you should alert your physician so that you may receive prompt treatment for depression.

Symptoms of a Major Depressive Episode:
•persistently depressed or irritable mood
•diminished interest or pleasure in activities
•significant decrease or increase in appetite, or weight loss or weight gain
•increased or decreased sleep
•decreased mental and physical activity, or increase in such activity as demonstrated by excessive worrying and agitated behavior
•fatigue, or loss of energy
•feelings of worthlessness or excessive or inappropriate guilt
•diminished ability to think or concentrate, or indecisiveness
•recurrent thoughts of death and dying, recurrent suicidal thoughts with a specific plan, or a suicide attempt

Understand the differences in symptoms of Borderline Disorder, Bipolar Disorder-Depressed and Major Depressive Disorder, and learn about the various plans for treatment for depression.

In order to initiate the proper treatment for depression, it is necessary to determine if you are experiencing a decrease in mood associated with borderline disorder, or if you have developed a bipolar II disorder- depressed or major depressive disorder.

Depressed Mood in Borderline Disorder

In borderline disorder alone, depressed mood often occurs as follows:
•sad, depressed, and lonely feelings are frequently triggered by some life event and are often associated with strong feelings of emptiness, loneliness and fears of abandonment.
•symptoms readily improve if the situation causing them improves
•sleep, appetite and energy disturbances (if present) are usually related to an identifiable life stress and stop when the stress is managed successfully.
•acute suicidal thoughts and self-injurious behavior are usually the direct result of a personal problem (for example, an argument with a parent, boyfriend, spouse, or boss)

Bipolar II Disorder-Depressed*

In bipolar disorder-depressed, the symptoms of a major depressive episode listed above are often characterized by:
•increased appetite or weight gain
•increased sleep and napping
•marked decrease in mental and physical activity
•marked fatigue and loss of energy

Major Depressive Disorder

In major depressive disorder, the symptoms of a major depressive episode listed above are often characterized by:
•decreased appetite or weight loss
•decreased sleep with early morning awakening
•increased mental and physical activity as demonstrated by excessive worrying and agitated behavior

Atypical Features

The essential characteristics of atypical features are the capacity to be cheered up when experiencing positive events and two of the following: increased appetite and weight gain, nighttime sleep and napping of at least ten hours duration, or two hours more than usual, feeling heavy, leaden, or weighted down, usually in the arms and legs, and moderate to severe sensitivity to rejection.

Treatment for Depression Co-occurring with Borderline Disorder

If you think you have the symptoms of either type of depression, immediately alert your psychiatrist. If appropriate, the treatment for depression frequently involves the addition of an antidepressant, an increase in dosage if one is already being used, and/or the use of behavioral techniques.

There are no controlled studies on the relative effectiveness of different antidepressants for the treatment for depression in people with borderline disorder. However, studies of these disorders in people without borderline disorder, and experience, suggest that the following initial treatment strategies may have merit:

Treatment for Depression in Bipolar Disorder-Depressed and Major Depression with Atypical Features
•Bupropion (Wellbutrin&orig;)* drug of choice
•Lamotrigine (Lamictal&orig;)
•SSRIs such as fluoxetine (Prozac&orig;) or sertraline (Zoloft&orig;) if bupropion and lamotrigine are ineffective

Treatment for Depression in Major Depressive Disorder without Atypical Features
•SSRIs such as fluoxetine or sertraline* drug of choice
•Bupropion and lamotrigine if SSRIs are ineffective

Note: It is important in the treatment for depression to recognize that some antidepressants may cause an episode of mania or hypomania in patients with depression who have never experienced such episodes in the past.

Cognitive Behavioral Therapy focused on
treatment for depression may also prove useful to help identify thought patterns and behaviors that operate as risk factors for mood disorders, and to encourage new, more successful behaviors.

* Bipolar I and II, and major depressive disorders occur more commonly in patients with borderline disorder than they do in the general population. Bipolar II disorder is the most common type of bipolar disorder that occurs with borderline disorder. People with bipolar II disorder do not experience manic episodes as do those with bipolar I disorder, but do experience brief hypomanic periods and recurring episodes of depression. Depressions associated with bipolar disorder appear to be related to depressions referred to as atypical depression and seasonal affective disorder (SAD).

Have you or a loved one been diagnosed with borderline disorder and are suffering from anxiety and panic attack symptoms?

Read the following article and learn more about these symptoms and how they are treated.

Anxiety and panic attack symptoms are common in people with borderline disorder. Symptoms of anxiety occur in almost 90% of people with borderline disorder. If you have borderline disorder, you may experience heightened levels of anxiety and panic attack symptoms, especially at times of stress. For example, this may occur when you feel you are personally criticized and rejected, or during periods of separation from people who are very important to you. Moderate to severe anxiety may also lead to physical symptoms, such as migraine headaches, abdominal pain and irritable bowel syndrome.

Panic Attacks

A panic attack is an acute and severe form of anxiety that occurs in about 50% of people with borderline disorder. Panic attacks are characterized by a discrete period of intense fear in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes:
◾palpitations, pounding heart, or increased heart rate
◾sweating
◾trembling or shaking
◾sensations of shortness of breath or smothering
◾feeling of choking
◾chest pain or discomfort
◾nausea or abdominal distress
◾feeling dizzy, unsteady, lightheaded, or faint
◾feelings of unreality or being detached from oneself
◾fear of losing control or going crazy
◾fear of dying
◾numbness or tingling sensations
◾chills or hot flashes

Symptoms can appear unexpectedly and suddenly, or for no apparent reason, and disappear either rapidly or slowly. People who suffer from anxiety and panic attack symptoms may also be fearful of placing themselves in circumstances from which escape may be difficult or embarrassing such as elevators, shopping malls and movie theaters. This is referred to as agoraphobia.

Treatment of Anxiety and Panic Attack Symptoms in Borderline Disorder

Effective treatment of disabling anxiety and panic attack symptoms in people with borderline disorder should be initiated promptly when these disorders occur. Such treatment usually consists of the use of medications and behavioral techniques.

The use of medications to treat anxiety and panic attack symptoms in patients with borderline disorder must proceed with care. This is so because these disorders are commonly treated with benzodiazepines (Xanax, Klonopin, Valium, etc.) that have been found to be harmful in most patients with borderline disorder because they increase impulsivity and have addictive potential. Therefore, in borderline disorder, other classes of medications are often required such as a temporary increase in the antipsychotic or mood stabilizer being used to treat the disorder. Initiating the use of an antipsychotic agent or a mood stabilizer may prove effective for moderate to severe anxiety and panic attack symptoms if one is not already prescribed.

In addition, a course of cognitive behavioral therapy or of biofeedback specifically tailored to target anxiety and panic attack symptoms are often considered as part of the long-term treatment of these problems.

Co- occuring Disorders

If you suffer from borderline disorder, you are more prone to develop certain other mental disorders than those who do not have borderline disorder.13,14 One of the most likely explanations of this is that some of the genes that increase the risk of developing borderline disorder also increase the risk for developing these other disorders as well.

The disorders that most often occur with borderline disorder include the following:
◾mood disorders: major depressive disorder; dysthymia; bipolar disorder (depressive disorders)
◾substance use disorders
◾anxiety/panic disorders
◾post-traumatic stress disorder (PTSD)
◾eating disorders: bulimia; anorexia nervosa
◾attention deficit hyperactivity disorder (ADHD)
◾other personality disorders

Often, the diagnosis of these disorders is made correctly in patients with borderline disorder, but the diagnosis of borderline disorder is missed. When this occurs, treatment for the other condition is typically less successful than it might otherwise be, mainly because the appropriate treatments for borderline disorder have not been utilized.

Conversely, the effective treatment of borderline disorder requires the prompt recognition of other disorders if they are also present and, if so, the appropriate additional treatment.

The early detection and effective treatment of a mental disorder co-occurring with borderline disorder may result in rapid improvement of the symptoms of borderline disorder if it is being properly treated itself. This is an added incentive to consider the presence of these disorders along with borderline disorder, and to treat them when present.

For these reasons, you and your psychiatrist should attempt to determine the presence of these co-occurring conditions, and to initiate promptly the appropriate additional treatments if indicated.

Causes

For many years, it was commonly believed that the main cause of borderline personality disorder was poor or uninformed parenting. It now seems most likely that both environmental and biological factors, especially genetic ones, place a person at risk for developing the disorder.4,9-12

For example, psychological and social (environmental) factors, including but not limited to poor parenting, increase the risk of developing the disorder in those people biologically predisposed to it.9 It appears that no single cause, or risk factor, is responsible by itself for causing the disorder. In fact, it now appears that a genetic predisposition for developing the disorder is necessary, and that environmental factors may increase the risk but are not essential.

Finally, it is generally held that biological and environmental risk factors interact to reach a certain critical level of brain dysfunction in order for the symptoms of borderline personality disorder to become apparent. It appears that this critical degree of disturbance of brain function can be achieved by a large amount of biological risk which requires only a low amount of environmental risk, low biological risk coupled with high environmental risk, or intermediate levels of both.

Biological Risk Factors

Research studies now suggest that 60% of the risk of developing borderline disorder is conveyed by genetic abnormalities.10 These abnormalities appear to affect the proper functioning of those brain pathways or circuits that serve the behavioral functions of emotion information processing, impulse control and cognitive activity such as perception and reasoning. Current research suggests that there is not a single, specific gene for borderline disorder. It appears that the genes that increase risk for the disorder may be passed on by people who have the disorder itself, or a related disorder, such as bipolar disorder, depression, substance use disorders, ADHD and posttraumatic stress disorder.

Environmental Risk Factors

Of all environmental factors that place a person at risk for developing borderline disorder, those associated with poor or uninformed parenting appear to be the most critical.9,11,12 These include early separation from one or both parents, repeated emotional, physical or sexual abuse by someone within or outside of the family itself, and inconsistent, unsupportive care. Poor parenting can also include failing to protect the child from repeated abuse by the other parent, another member of the family, or an outsider.

It is important to understand that children who have not been exposed to such environmental traumas can still develop borderline disorder. This suggests that in some people the biological risk of developing the disorder is very high, and may be sufficient in the absence of environmental traumas

Course Of The Disorder

Adolph Stern’s comprehensive description of the main features of borderline disorder in 1938 5 was followed by almost forty years of general ignorance of and pessimism about the disorder. Among many of those who knew something of it, borderline disorder was typically regarded as an ill-defined and difficult to treat disorder that rarely improved. However, over the past thirty years, a rapid expansion of research on borderline disorder has greatly altered these incorrect perceptions and beliefs.

The following is a list of some of the most important and valid findings on the course of borderline disorder from this body of research.8

Age of Onset

The full spectrum of symptoms of borderline disorder appears most commonly in the teenage years and in early adulthood.

It is difficult to diagnose the disorder accurately in children. In some people, the symptoms may first become evident in mid to late life.

Progression of Symptoms

After their onset, the symptoms of borderline disorder initially may increase in number, frequency and severity, especially if untreated. Symptoms often occur episodically on a background of otherwise relatively normal behavior.

These episodes are most commonly triggered by stressful situational events, such as arguments with parents or boyfriends/girlfriends, separations, family gatherings, changing schools, starting college or a new job, or moving. As time passes, some symptoms may become less severe in intensity, such as impulsivity and general social functioning. Other symptoms of borderline disorder may remain fairly stable over time, including impaired emotional control, self injurious and suicidal behaviors and tolerance of separations from important others.

Severity of Symptoms

The number and severity of symptoms of borderline disorder vary considerably from one individual to another. You may have the minimum of five of the nine criteria required for the diagnosis of the disorder, and these symptoms may be of mild severity. Or, you may have eight or even nine of the criteria, with most at a severe level. Finally, you may fall somewhere between these two extremes. If you have one to four of the nine criteria, you are considered to have
traits of borderline disorder and can still benefit from treatment.

Prognosis

The general prognosis, or expected outcome, for people with borderline disorder is more positive than previously believed. Recent studies report that up to 88% of people with the disorder experience significant improvement over time. 8

The degree of improvement primarily depends on a number of factors, some of which include:

Indicators of more positive outcome: low initial severity level, promptness of detection, high quality of treatment, current and past history of fairly good relationships, and a good vocational record.

Indicators of less positive outcome: high initial severity, early history of sustained emotional, physical or sexual abuse and neglect, impulsivity, substance abuse, poor quality of past and current relationships, presence of PTSD, and a family history of mood or substance use disorders.

It is important to realize that these indicators are not equally important. Also, if you have some, or even many of indicators of poorer outcome, with effective treatment by experienced clinicians you can still experience substantial improvement in your symptoms, and in the quality of your life.

History Of The Disorder

Initially, it was suggested that borderline disorder bordered on, or overlapped with schizophrenia, non-schizophrenic psychoses, and neuroses such as anxiety and depressive disorders.3 Because it overlapped with so many other psychiatric diagnoses, it was commonly believed to be a “wastebasket” diagnosis, lacking in diagnostic precision and validity, and only useful for patients who did not fall clearly into other diagnostic categories. It also was thought that the disorder responded very poorly to treatment. Unfortunately, a large number of mental health professionals, apparently unfamiliar with the current scientific literature, still think that this is true.

However, many research studies have now shown that borderline disorder does have diagnostic validity and integrity.3 Some of these studies indicate clearly that the disorder does not overlap with schizophrenia. Also, the disorder does appear to be a distinct diagnostic entity, although it co-occurs frequently with other mental disorders such as major depressive and bipolar II disorders, attention deficit hyperactivity disorder (ADHD), substance use disorders, post-traumatic stress disorder (PTSD), and with several other personality disorders.3

Finally, medications and specific forms of psychotherapy have been shown to be effective in the treatment of borderline disorder, thereby giving substantial hope to those who suffer from it, and to their families and friends.

The following is a brief historical review of the major advances in our understanding and treatment of borderline disorder.
◾Descriptions of individuals demonstrating the symptoms of borderline disorder were first mentioned in the medical literature almost 3000 years ago.4
◾In 1938, the American psychoanalyst Adolph Stern first described most of the symptoms that are now considered as diagnostic criteria of borderline disorder.5 He suggested the possible causes of the disorder, and what he believed to be the most effective form of psychotherapy for these patients. Finally, he named the disorder by referring to patients with the symptoms he described as “the border line group.”
◾The psychoanalyst Robert Knight, in the 1940s, introduced the concepts of ego psychology into his description of borderline disorder. Ego psychology deals with mental functions that enable us to realistically perceive events, successfully integrate our thoughts and feelings and to develop effective responses to life around us. He suggested that people with borderline disorder have impairments in many of these functions, and he referred to them as “borderline states.” 4
◾The next major contribution in the field was made by the psychoanalyst Otto Kernberg. In the 1960s, he proposed that mental disorders were determined by three distinct personality organizations: psychotic, neurotic and “borderline personality.” Kernberg has been a strong proponent of modified psychoanalytic therapy for those patients with borderline disorder who are able to benefit from it. 4
◾In 1968, Roy Grinker and his colleagues published results of the first research conducted on patients with borderline disorder, which he referred to as the “borderline syndrome.” 4
◾The next major advance occurred in 1975 when John Gunderson and Margaret Singer published a widely read article that synthesized the relevant, published information on borderline disorder, and defined its major characteristics. Gunderson then published a specific research instrument to enhance the accurate diagnosis of borderline disorder. This instrument enabled researchers over the world to verify the validity and integrity of borderline disorder. Subsequently, borderline personality disorder first appeared in DSM-III as a bona fide psychiatric diagnosis in 1980. 4
◾In 1979, John Brinkley, Bernard Beitman and Robert Friedel proposed that medications, specifically low doses of neuroleptics (now referred to as antipsychotic agents), are effective in reducing some of the symptoms of borderline disorder. 6 Friedel’s research team published support for this proposal in 1986 in one of the first two placebo-controlled studies of any medication in subjects with borderline disorder. A similar finding was reported in the same journal by Paul Soloff’s research team with a different medication in the same class. Since then, other controlled studies of similar agents have supported and extended the original finding. In addition, medications in other classes have been reported to have efficacy in treating the symptoms of borderline disorder. 27
◾In the 1980s, the first of a large number of neuroimaging, biochemical and genetic studies were published indicating that borderline disorder is associated with biological disturbances in those brain areas related to the symptoms of the disorder. 23
◾In 1993, Marsha Linehan introduced Dialectical Behavior Therapy (DBT), a specific and now well documented form of psychotherapy for patients with borderline disorder prone to self injurious behavior and who require and request frequent, brief hospitalizations. 34 Since then, other forms of psychotherapy have been developed that are specifically designed for borderline disorder.
◾Over the past decade, two lay advocacy groups have been founded, the Treatment and Research Advancements Association for Personality Disorder (TARA APD), and the National Education Alliance for Borderline Personality Disorder (NEA- BPD). The missions of these organizations are: to increase the awareness of borderline disorder and its treatments; provide support to those suffering from the disorder, and to their families and friends; enhance the federal and private research funding dedicated to borderline disorder; and to decrease the stigma associated with the disorder.7

Borderline Disorder From The Inside

There is one study in the literature that provides an especially helpful perspective on borderline disorder that adds effectively to the information presented in the clinical description on this website.2 I believe that these reports from patients will help you to understand more completely what it feels like to suffer from borderline disorder.

Of course, there is no single view of borderline disorder that adequately captures all of your experiences. However, this material, directly quoted from my book, Borderline Personality Disorder Demystified, may be of help to you.

“In 1994, Sharon Glick Miller, a psychologist in the Department of Psychiatry at the University of Florida, published a study of 10 patients (8 women and 2 men) with borderline disorder from whom she obtained life-history narratives in a series of 90-minute interviews over a one-year period. After careful analysis of the data, she concluded that the self-reports of these patients were highly consistent, but differed significantly from typical clinical descriptions.While clinicians described these patients as having an impaired sense of self (an identity problem), they seemed to have a sense of themselves as impaired. They reported that the strategies they used, such as changes in appearance, might seem like an identity problem, but they were mainly attempts to feel better about themselves. They also indicated that they did not reveal themselves readily to therapists or to others because they anticipated disapproval, and would rather appear to be lacking in identity than have confirmed their perceptions of themselves as flawed.They did not see themselves as having an illness, but as leading a life in which they constantly struggled against feelings of despair. This was a central theme of how they perceived their fate in the world.Most patients reported feeling alone and inadequate, beginning in some as children, and in others as adolescents. This was so in spite of their achievements. For the most part, they did not know the origins of these feelings, though two identified family disturbances and another the discrimination she experienced because of obesity. The sense of emotional pain and despair they reported was overwhelming. They all expressed the wish not to be alive.

Coping Strategies.These patients each developed a number of coping strategies to lessen the sense of pain and despair, always with the hope that, just once, something would help. The main coping strategy was attempting to block out or dissociate themselves from these feelings as best they could. If that was not successful, many turned to alcohol and drugs.

Patients viewed their bedrooms or apartments as safe havens, except when they were depressed. At these times, some realized that it was dangerous to be alone because of the great impulse to hurt themselves. Social situations typically provoked anxiety and feelings of inadequacy. These feelings resulted in strategies either to push through the event, which exacted a high toll on their energy, or to escape from the situation.

One potential coping strategy was notable because of its relative absence, the use of social support. Patients consistently reported that they did not openly share their feelings with family, friends and even their therapists because of fears of rejection, and of being viewed as a burden. However, not sharing their struggles resulted in the worsening of their sense of isolation.

They also felt conflicted about sharing negative feelings with their therapist. To not do so could be perceived as not working in therapy, but doing so could reveal a lack of progress that might result in increased pressure to perform, or in hospitalization. Hospitalization was viewed primarily as a respite from the constant struggles with despair and the desire not to be in this world. Once the crisis was over, they then wished to be discharged. However, they learned they could not refer often to their constant thoughts of self-harm as this might result in an undesired hospitalization.

The Importance of Self-Disclosure. An important finding from this study was that patients felt more comfortable revealing information in the research setting than elsewhere, because no challenges were being made to their presentations. Subsequently, they believed the researchers understood them better than their families, friends and even some of their therapists. They perceived themselves to be collaborating with the researchers because they were the experts about themselves, which helped reduce their conflicts over dependency issues.”

Symptoms OF BPD

There are nine specific diagnostic criteria (symptoms) for borderline personality disorder defined in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (referred to as DSM-IV-TR, or just DSM-IV) published in 2000 by the American Psychiatric Association.1 In order to be diagnosed with borderline disorder, you must have five of the nine criteria.

It is now common to list the symptoms of the disorder in four groups or dimensions:

1. Excessive, unstable and poorly regulated emotional responses.
The most commonly affected emotions are anger, anxiety and depression. Of the nine DSM-IV criteria for borderline disorder, three fall into this group:
◾Affective (emotional) instability including intense, episodic emotional anguish, irritability, and anxiety/ panic attacks
◾Anger that is inappropriate, intense and difficult to control, and
◾Chronic feelings of emptiness

In addition, if you suffer from borderline disorder, you may also experience
◾Emotional over reactivity (“emotional storms”)
◾Emotional responses that are occasionally under reactive, and
◾Chronic boredom

2. Impulsive behaviors that are harmful to you or to others.
Two of the DSM-IV criteria for borderline disorder are in this group:
◾Self-damaging acts such as excessive spending, unsafe and inappropriate sexual conduct, substance abuse, reckless driving, and binge eating, and
◾Recurrent suicidal behavior, gestures, threats, or self-injurious behavior

Also, you may engage in other impulsive behaviors such as actions that are harmful and destructive to yourself, others or to property.

3. You may have an inaccurate view of yourself and others, and experience a high level of suspiciousness and other misperceptions.

Two of the DSM-IV criteria for borderline disorder are included in this group:
◾A markedly and persistently unstable self-image or sense of your self (your identity), and
◾Paranoid ideation or severe dissociative episodes (transient and stress related)

In addition, you may consistently experience
◾Expectations of negative and harmful attitudes and behaviors from most people
◾Impaired social reasoning under stress
◾Impaired memory under stress

4. Finally, you may experience tumultuous and very unstable relationships.

The final two DSM-IV criteria fall in this group:
◾You may engage in frantic efforts to avoid real or imagined abandonment, and
◾Your relationships may be very intense, unstable, and alternate between the extremes of over idealizing and undervaluing people who are important to you

You may also recognize that you have overly dependent and clinging behavior in important relationships.

What is BPD?

Borderline personality disorder is a disturbance of certain brain functions that causes four types of behavioral disturbances:
1.poorly regulated and excessive emotional responses;
2.harmful impulsive actions;
3.distorted perceptions and impaired reasoning; and
4.markedly disturbed relationships.

The symptoms of borderline disorder were first described in the medical literature over 3000 years ago. The disorder has gained increasing visibility over the past three decades. The full spectrum of symptoms of borderline disorder typically first appears in the teenage years and early twenties. Although some children with significant behavioral disturbances may develop readily diagnosable borderline disorder as they get older, it is very difficult to make the diagnosis in children.

After its onset, episodes of symptoms usually increase in frequency and severity. Remissions, relapses, and overall significant improvement with treatment is the most common course of the illness.8 Borderline disorder appears to be caused by the interaction of biological (genetic) and environmental risk factors, such as poor parental nurturing, and early and sustained emotional, physical or sexual abuse.

Physical disorders, such as migraine headaches, and other mental disorders, such as depression, anxiety, panic and substance abuse disorders and ADHD, occur much more often in people with borderline disorder than they do in the general population.