Borderline personality disorder: Definition, differential diagnosis, clinical contexts, and therapeutic approaches

Defi nition, introduction and epidemiological profi le: The term “borderline” was born as a label aimed at describing a whole series of characteristics and behaviors that are diffi cult to defi ne. Migone (1990) draws up a list of the defi nitions of different authors, which refer more or less directly to the borderline area, below some: “borderline neurosis” (Clark, 1919), “parataxies in certain borderline mental states” (Moore, 1921), “impulsive character”, “incipient schizophrenia” (Glover, 1932), “atypical schizophrenia” or “affective schizophrenia” (Kasanin, 1933), “outpatient schizophrenia” (Zilboorg, 1941), “personality as if” (Deutsch, 1942), “latent psychosis” (Federn, 1947), “pseudonevrotic schizophrenia” (Hoch & Polatin, 1949), “latent schizophrenia” (Bychowsky, 1953), “psychotic character” (Frosch, 1954, 1960), “attenuated schizophrenia” (Ekstein, 1955), “histeroids” (Easser & Lesser, 1965), “atypical psychosis”, “borderline schizophrenia” (Kety, et al. 1968), “hysteroid dysphoria” (Klein & Davis, 1969; Klein, 1977), “borderline psychosis”, “indescribable patients” (Welner, et al. 1973), “subaffective disorder” (Akiskal, 1981) [1].

In those same years, Kohut dealt with "narcissistic personality disorders", which identifi ed a series of relationship diffi culties and profound defi cits in narcissistic development.
A strong controversy arose between this author and Kernberg regarding the actual classifi cation of this type of disorder. If for Kernberg, the patients defi ned as "narcissistic" represented a particular typology within his borderline personality organization, for Kohut instead they responded to another structural need: these patients were still able to function in everyday life, perfectly integrating, since the central nucleus of their problem was in an evolutionarily frozen Self to a phase in which it did not receive the answers of admiration necessary for its healthy development. What emerged from this cultural clash was a certain perplexity about its correctness, since the patients of one were very different from those of the other: Kohut (privately) treated patients who complained of a sense of emptiness, forms of depression and relationship diffi culties, while Kernberg (who worked in hospitals) dealt mostly with hospitalized patients, with sometimes even antisocial characteristics [3,4].
In subsequent years, however, also to remove any theoretical diatribe (such as the one born between Kernberg and Kohut), it was preferred to rely on the concept of personality disorder, as a specifi c class of structural mental disorder, comprising different "organizations". Not surprisingly, in the DSM diagnostic classifi cation manual, also in its latest version (the fi fth), among the personality disorders, in cluster B, both Borderline Disorder (described by Kernberg, although originally the author) are included separately wanted to propose a class/ organization of disorders on the border between neurosis and psychosis) that the Narcissistic Disorder [5].
The original idea was therefore referred to patients with personalities who work "on the edge" of psychosis, even if they do not reach the extremes of real psychoses (such as schizophrenia). This defi nition is now considered more appropriate to the theoretical concept of "Borderline Organization", which is common to other personality disorders, while borderline disorder is a particular picture of it. Borderline organization is also found in the extremes of various mood swings, such as severe depression or nonpsychotic bipolar disorder, and in other serious forms of pathology, but without real psychosis. The formulations of the DSM and ICD psychodiagnostic manuals have restricted the name of "borderline disorder" to indicate, more precisely, that pathology whose symptoms are emotional dysregulation, the instability of the subject in interpersonal relationships, and marked impulsiveness, thus suggesting a change of name of the disturbance [5,6].
The prevalence of borderline disorder was initially estimated between 1% and 2% of the general population [7,8] and is found three times more frequently in women than in men [9,10]. However, the one-time prevalence of the condition found in a 2008 study was 5.9% of the general population, with 5.6% of men and 6.2% of women [11]. More likely estimates, compared to the fi nding data coming from clinical practice, it is estimated that borderline personality disorder (in its traits or its chronic morbid condition) contributes more than 20% of Citation: Perrotta G (2020) Borderline personality disorder: Definition, differential diagnosis, clinical contexts, and therapeutic approaches. Ann Psychiatry Treatm 4(1): 043-056. DOI: https://dx.doi.org/10.17352/apt.000020 psychiatric hospitalizations, although many of these subjects do not present an offi cial conclusive diagnosis; complicit in this exponential growth are, in the writer's opinion, the spread of incorrect and dysfunctional behaviors acquired through social networks and the family environment [6,12].

Etiological profi le:
The hypothesized causes for bipolar disorder are heterogeneous and include biological, genetic, and environmental factors [5].
Borderline personality disorder has often been associated with traumatic events in childhood (then developed following a post-traumatic stress disorder in childhood), such as sexual or physical abuse, or being raised with parents with behavioral problems or mental disorders (such as schizophrenia, bipolar disorder, and schizoaffective disorder). Some have suffered early separation from a loved one, bereavement in childhood, other problems, or are children of a dysfunctional family. Adler instead claimed that the intimate pain and intolerance were due to the impossibility of these subjects to recall comforting affective experiences, caused by the real lack in which comfort and protection were received in the face of feelings of danger, loneliness and anxiety that the family environment had created; in fact, the borderline patient does not develop comforting and containing object representations to call to mind in moments of separation from the maternal fi gure, even if some borderline patients do not report in their childhood clinical history an abandonment depression due to the absent mother (at most a mother presence but with a dysfunctional or incorrect educational style, in the presence of a strong anxious, obsessive or paranoid trait); in these cases, Masterson and Rinsley argue that the mothers of these borderline patients are themselves suffering from a borderline or mood disorder, or from anxiety, or paranoia, and are unable to promote a correct separation process, and usually -even completely unconsciously and without fault -implicitly teach that the conquest of greater autonomy will lead to a loss of love and protection of the mother herself, and that growth and separation will still produce pain (therefore they have a parenting style of overprotective care with a symbiotic mother-child bond, which for psychoanalysis corresponds to an unsolved Oedipus complex of the child). For Kernberg, the patient suffers from psychoanalytic fi xation in the sub-phase of rapprochement, the period between sixteen and twenty-four months according to Mahler's model, a different and integrative development model of the classic phases of psychosexual development according to S. Freud; in this case, the child does not learn to have a proper distance from the mother, even if he loves her and cares for her after a period of estrangement, as normally happens and instead cannot bear expectations and frustrations, fearing to be abandoned and left alone, arriving internally not to feel safe from the fear of loss (thought with which he will never come to terms while trying to remove it). Again according to this model, his attachment also makes detachment very diffi cult when attending schools, isolates himself from peers, or interacts with the environment through conduct disturbances towards classmates, hyperactivity/distraction towards teaching, and oppositional disturbance-provocative towards adults who upset him. The child and adolescent do not learn to manage their emotions, which remain in a primitive-impulsive state, very childish, even though intelligence is normally developed.
Also on this profi le, parents demonstrate immaturity in the management of their interpersonal relationships, which are often hostile, or morbid, anxious, paranoid, thus confi guring an evident trace of the severely dysfunctional family nature to which the child, even the fi rst infant, was a victim [13,14]. Therefore, stressful events during early childhood can contribute to the development of borderline personality disorder. A remote history of adolescent physical and sexual abuse, neglect, separation of parents, and / or loss of a parent is common among patients with borderline personality disorder.
Some people may then have a genetic tendency to have pathological responses to stressful environmental conditions, and borderline personality disorder appears to have a hereditary component. First-degree relatives of patients with borderline personality disorder are fi ve times more likely to have the disease than the general population. Finally, disturbances in the regulatory functions of brain systems and neuropeptides may also contribute, but are not present in all patients with borderline personality disorder [5]. In conclusion, the existence of four possible etiopathogenetic models, even simultaneous, for borderline personality disorder can be hypothesized [15].
Brain damage, prevalent at the level of the orbitallimbic-frontal region, could cause a disturbance of impulse control, emotional and affective instability, specifi c cognitive dysfunctions, and a vulnerability to psychotic decompensation.
The predisposing neuro-biological condition could depend on anatomic-functional damage, cognitive dysfunction, and limbic hyperactivity, with or without epileptic seizures, or monoamine neurochemical alterations, involving the serotonergic and dopaminergic brain tone. The clinical, social, and interpersonal symptomatology would however be modulated subsequently by social, educational, and traumatic factors.
Patients could coexist in their childhood with other family members, often the parents themselves, with the same disorder. This would expose patients to disturbing behaviors such as substance abuse, the instability of parental fi gures, the confl ict expressed between parents, as well as episodes of physical and / or sexual abuse. Behaviors of this kind can persistently alter normal psycho-sexual development and induce dysfunctional behavioral patterns through learning by imitation. The emergence of a borderline personality could lead, in this perspective, to a disorder of the patient's development due to exposure to aggressive behaviors, implemented by family members, with a similar developmental disturbance.
Paradoxically, the development of this personality disorder could be adaptive to the family context in which the patient lived in childhood and adolescence [16,17].
Borderline personality disorder is to be considered as an impulse control disorder, with aspects of genetic predisposition. Poor impulse control would facilitate the risk of brain damage, traumatic or substance abuse, which, in turn, may worsen the pre-existing impulse control disorder with consequent and secondary cognitive defi cits. In some patients, brain dysfunction may not depend on a previous impulse Citation: Perrotta  control disorder, playing the role of the main and organic cause of impulsivity in this subpopulation of patients with borderline personality disorder. Impulsive behaviors and related cognitive aspects, in the absence of self-control and modulation skills in interpersonal relationships, would induce repeated failures in emotional and social relationships, subsequently associating with depression, anger, and dissociative episodes. From a purely genetic and biochemical point of view, several genes have been identifi ed in the last ten years as responsible for   the genesis of the disorder: COMT, DAT1, GABRA1, GNB3,   GRIN2B, HTR1B, HTR2A, 5HTT, MAOA, MAOB, NOS1, NR3C1,   TPH1, and TH, which coincide with the regulation of some key neurotransmitters, including serotonin, GABA, glutamate, dopamine, noradrenaline, and the neuropeptides oxytocin, neuropeptide Y and the corticotropin release factor [18,19]. In DSM-III-R (APA, 1987), the diagnostic criteria remain unchanged and fi ve of these are necessary to make a diagnosis [ [5].
The DSM-IV-TR criterion, reported in DSM 5 (unchanged), for Borderline Personality Disorder, is a pervasive pattern of instability of interpersonal relationships, self-image and mood and a marked impulsiveness, which begins by early adulthood and is present in various contexts, as indicated by fi ve (or more) of the following elements [5]: 1) Desperate efforts to avoid a real or imaginary abandonment (does not include the suicidal or selfmutilating behaviors considered in Criterion 5).
2) A pattern of unstable and intense interpersonal relationships, characterized by the alternation between the extremes of hyper-idealization and devaluation.
3) Alteration of identity: self-image or self-perception markedly and persistently unstable. 4) Impulsiveness in at least two areas that are potentially harmful to the subject (for example, reckless expenses, sex, substance abuse, reckless driving, binge eating). 5) Recurrent suicidal behavior, gestures or threats, or selfmutilating behavior.
6) Affective instability due to a marked mood reactivity (for example, episodic intense dysphoria, irritability, or anxiety, which usually lasts a few hours and only rarely more than a few days).
The alternative model proposed in Section III of DSM 5 [5], presents itself with the instability of self-image, personal goals, interpersonal relationships and affects, accompanied by impulsiveness, a tendency to take risks and / or hostility.
Characteristic diffi culties are evident in: identity, selfdirection, empathy and / or intimacy, as described below, as well as specifi c maladaptive traits in the areas of negative affectivity and antagonism and / or inhibition: 1) Moderate or more serious impairment of the functioning of the personality, which manifests itself with characteristic diffi culties in two or more of the following four areas: a) Identity: markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. b) Self-directionality: instability in objectives, aspirations, values , or projects related to the profession. c) Empathy: Impaired ability to recognize the feelings and needs of others, associated with interpersonal hypersensitivity (for example, tendency to feel offended or insulted); perception of others selectively distorted concerning their negative characteristics or vulnerabilities. d) Intimacy: intense emotional relationships, unstable confl icts, characterized by distrust, dependence, and anxious concern for abandonment, real or imagined; emotional relationships often oscillating between the extremes of idealization and devaluation and alternating between excessive involvement, detachment.
2) Four or more of the following seven pathological personality traits, at least one of which must be impulsiveness, tendency to take risks, I have hostility: a) Emotional ability (an aspect of negative affect): unstable emotional experiences and frequent mood swings; emotions that arise easily, are intense and / or disproportionate to events and circumstances.
b) Anxiety (an aspect of negative affectivity): intense sensations of nervousness, tension or panic, often in reaction to interpersonal stress; concern about the negative affects of past unpleasant experiences and future negative eventualities; feel fear, apprehension or feel threatened by uncertainty; fear of "collapsing" or losing control. c) Separation anxiety (an aspect of negative affectivity): fear of being rejected and separating from signifi cant fi gures, associated with fears of excessive dependence and complete loss of autonomy. d) Depressive (an aspect of negative affectivity): frequently feeling sad, unhappy, and / or hopeless; diffi culty in recovering from these moods; pessimism about the future; pervasive shame; feelings of low esteem; suicidal thoughts and suicidal behavior. e) Impulsiveness (an aspect of disinhibition): acting immediately in response to contingent stimuli; acting on a momentary basis, without a plan or an examination of the results; diffi culty formulating and following plans; the sense of urgency and self-injurious behavior under emotional stress.
f) The tendency to take risks (an aspect of disinhibition): undertake dangerous, risky, and potentially harmful activities for oneself, without need and without worrying about the consequences; the carelessness of one's limits and denial of the real danger to the person. According to the ICD, emotionally unstable personality disorder is described as an individual personality disorder characterized by a certain propensity for impulsive actions without taking into account the consequences, with the following characteristics: [5] 1) Unpredictable and capricious mood; 2) Tendency to burst of emotions and inability to control explosive behavior; 3) Grievances and confl icts with others, especially when impulsive actions are repressed and criticized.
It is divided into two types: distinguishing these four areas [5].
1) Vision of oneself: They consider themselves defective, vulnerable to abuse, betrayal, neglect. "I'm bad", "I don't know who I am", "I am weak and I feel overwhelmed", "I can't help myself"; 2) Vision of others: They can see others as warm and affectionate but still consider them unreliable because "they are strong and could be supportive, but after a while, they change to hurt or abandon me"; 3) Intermediate and profound beliefs: "I have to ask what I need", "I have to answer when I feel attached", "I have to do it because I have to feel better", "If I am alone, I will not be able to face the situation", "If I trust someone, sooner or later he will abandon me or abuse me and I will be sick", "if my feelings are ignored or neglected, I will lose control"; 4) Coping strategies: Submitting, alternating inhibition with a dramatic protest, punishing others, expelling tension with self-injurious actions.
Personality disorder can, therefore, be seen as a dysregulation disorder; therefore, its clinical characteristics can be grouped into fi ve main areas [5].
1) "Emotional dysregulation", characterized by affective instability and problems in anger management; 2) "Interpersonal dysregulation", characterized by chaotic relationships and fear of abandonment; 3) "Self-dysregulation", characterized by identity disorders and feelings of chronic emptiness; 4) "Dysregulation of behavior", characterized by self-harm and self-destructive conduct; 5) "Dysregulation of thought", characterized by dissociative responses under stress and paranoid ideation.
Their psychopathological condition, however, essentially depends on their "level of insight" concerning the external (reality and environment) and internal (the relationship between the deep instances) plan and consequently also the psychological treatment will have to adapt to the clinical form suffered [5]. 2) The "Self-Vulnerable", or the perception of being easily injured and having no defenses and ability to cope with catastrophic events, both external and internal. In this core, From these therapeutic cycles the patient can obtain validation, protection, and comfort, even if temporarily. The reason why these cycles are short and fragile is linked to the tendency to invest in the other, idealizing him and setting excessive expectations that can easily be invalidated. The unworthy self, when it receives validation, leads the patient to experience himself as a deceiver, as if he had played a role. Another reason that makes the therapeutic cycle temporary is the fact that the patient's request for help and validation can be made in a pressing and aggressive way, causing fear and discomfort in the other and transforming the protective cycle into an alarm cycle. The patient with this pathological disorder perceives himself as wrong, monstrous, inept, has an idea of himself as unworthy, and fi nds himself in a state of continuous self-invalidation, denigration, and anger towards himself. In fear of being injured, abandoned, and criticized and perceiving himself as vulnerable, he experiences fear, anxiety and may experience dissociative symptoms. The underlying desire for the patient's behavior is to be protected and cared for and requires it manifestly, he perceives and expects the other to neglect him, abandon him and mistreat him. At that point the patient feels abandoned and feels anger at the injustice he underwent, closes himself to avoid other abandonments, but due to the need for care he reactivates himself and fi nds himself again in an interpersonal cycle of this type [20] Diff erential diagnosis: In the psychodiagnostic fi eld [5,21] proceeding with a diagnosis of a possible personality disorder is very complicated, because it is necessary to consider many elements and different factors. In the practical clinic, three main models are used to make a diagnosis: 1) Nosographic model of the DSM, which provides a general, uniform and schematic nomenclature of the symptoms; 2) Kernberg's structural model, which is based on the intuition that psychopathological disorders must be classifi ed according to three areas (neurotic, borderline and psychotic) and that each of these is the reference container does not refer to "typologies" (of whatever type they are) but identifi es a diagnosis calibrated exactly on the person. The result is a highly specifi c intervention, an integrated therapy which, intervening on all levels of the Self, aims to recover and reconstruct the ancient "Basic Experiences of the Self".

The neural correlates in borderline personality disorder
with hyperactivity of the amygdala and the medial part of the prefrontal cortex, areas assigned to emotional and cognitive processing of stimuli [54].

Clinical strategies for the management of the disorder
Although personality disorders are generally considered to be the most diffi cult psychopathological disorders to manage, precisely because of the low collaboration of the patient, especially those of Cluster A and B, the best clinical strategy is considered the integrated one: psychotropic drugs, to stabilize, and psychotherapy (cognitive-behavioral and strategic) to teach the patient how to manage and accept his condition [5].
In particular, concerning psychotherapy, the technique   it considered a useful therapeutic practice [55].

Conclusions
Borderline disorder is classifi ed as a personality disorder, in cluster "B", and is characterized by emotional dysregulation, by an instability of the subject in interpersonal relationships and by a marked impulsiveness. It is often associated with traumatic events suffered in childhood (therefore developed following a post-traumatic stress disorder in childhood), such as sexual or physical abuse, or having grown up with parents suffering from behavioral problems or mental disorders. Etiology is not yet known but research shows the multifactorial nature of the disorder, to be found in neurobiological, environmental, and behavioral conditions. The best clinical treatment is certainly the integrated one, between psychotherapy (cognitive-behavioral, functional or strategic) and administration of psychiatric medicines.