The territory of personality disorders, both conceptually and clinically, has a particular complexity and dynamics. Personality is the core of the ground on which the multitude of mental and somatic illnesses begin and evolve. The structural dominance of the personality, regardless of the fact that they are mainly inherited or acquired during the first decades of life, can favor the peculiarities of the onset, the clinical and evolutive ones, as well as the therapeutic responsiveness of a variety of diseases. Starting from these aspects, the correct diagnosis of a personality disorder must be made as early as possible and should also integrate an important evolutionary component. In this context, the psychiatric team must necessarily and compulsorily expand with the participation of general practitioners(1,3).
Inherited dominant personality traits, such as reactivity, energy tone, communication and relationship peculiarities, and those related to background disposition, along with genetic vulnerability, perinatal factors, integration in the educational and social process with congeners can be initially recognized by the general practitioner. He also has access to the social and family environment in which the maladaptive psycho-behavioral manifestations appear(2,3).
Borderline personalities – currently the most frequent and severe personological diagnosis – occupy a special position in the field of personality disorders(4,5).
Although integrated in Cluster B by the complexity of maladaptive psycho-behavioral manifestations, which are the expression of both the homonymous features and a variety of psychopathological symptoms of Axis I, they are outlined as a multidimensional heterogeneous entity. This is confirmed by the evolutionary-prognostic features and the resistance to treatment. The leading position in the personological studies of the borderline personality is also due to the biological, psychological and social risk factors involved in its determinism. Thus, the genetic vulnerability and immaturity of the parental ego are found in the ego structure of the borderline personality. It is well known that the parental families of patients with borderline personality have a high rate of personality disorders and/or Axis I diseases(6,7).
Children from borderline mothers have a low level of self-control and concentration in relation to their congeners. They are also more exposed to physical and sexual abuse and are often the victims of their own mothers. As a consequence, both the theme of abandonment and the possibility of reversing roles as psycho-behavioral traits of children are cultivated(8-10).
In the same context, subjects with borderline features report that in childhood they always felt the lack of goodwill in the expressions of the faces and attitudes of the people who provided them with care. As a result, they have almost permanent anxious feelings and negative expectations related to the entourage, which can be detected later and in the relationships with the medical staff as well. Also consistent with early personogenesis, it is confirmed that the various emotional, material and relational deficiencies in the parental family cultivate ambivalent and anxious attachment relationships which subsequently negatively condition the stability and harmony of image and self-esteem(6,11,12).
It is also well known that the influences of social and cultural environment can change the different variants of attachment. The sociocultural dynamics of the last decades can favor pathological structurations of the personality whose severity can exceed the maladaptive attributes of the borderline personalities. Thus, the changes corresponding to the family structure marked by divorces, cohabitation and the almost total disappearance of families with several children disadvantage the introjection of family behavioral patterns and values and may change the nature of interpersonal relationships in the future. This can also have a negative impact on social relationships and behaviors(13,14).
The most frequently involved risk factor in the etiopathogenesis of borderline structures is physical, emotional or sexual abuse during childhood. But emotional instability, impulsivity, sensitivity and inadequate emotional reactions also have important genetic conditioning. Biological vulnerability along with the severity and diversity of psychotrauma affect the maturation of the social-cognitive processes involved in the mentalization process(14,15).
Mentalization is a cognitive social construct that corresponds to the ability to perceive and anticipate the desires, feelings and thoughts of others. The capacity for mentalization is flawed in borderline structures and substantiates the dysfunction of interpersonal relationships. Recent studies have shown that severe psychotrauma is directly associated with the inability to recognize the emotions of others related to the phenomenon of mentalization(14,16-18).
This also explains the inability to recognize one’s own emotional feelings, as well as the vitiated differentiation of positive and negative emotions from others, a phenomenon much studied by evaluating facial expression(19,20).
Borderline structures have always a negative perception of those around them whose attitude they consider untrustworthy, insecure or even malicious. Any interpersonal relationship is anxiously anticipated and, as a result, becomes a priori insecure and short-lived also, because it is marked by the fear of abandonment. And for this reason, addictive attachment is the foundation of maladaptive behavior in borderline personalities. According to Bateman and Fonagy, only 6-8% of patients with borderline personality disorder have stable attachment relationships. The negative significance attributed to the messages of those around them by borderline patients explains the fear of abandonment and interpersonal conflict, as well as emotional fluctuations and suicide attempts(5,19,21,22).
The fragility of the ego of borderline patients may explain the increased frequency and severity of impulse control disorders that accompany the sick biography. Comorbidities such as anorexia, bulimia, pathological gambling and substance abuse are well known. Bornstein describes the fact that borderline traits are present in subjects with anorexia (29%) and bulimia (31%). In these conditions of comorbidity, the symptoms corresponding to eating disorders are more severe and the functionality in the roles is significantly lower, which aggravates the prognosis(23,24).
Alcohol abuse has both an affective cause corresponding to anxious feelings and emotional lability and one related to the need to seek the sensations characteristic of borderline structures. Biological conditioning of these structural attributes outlines the predisposition to chronic addictive behavior(25).
The anarchy of the affective life motivates the severity of the emotional decompensations of anxious and depressive type, including the suicide attempts always marked by the attribute of impulsivity. It should be noted that suicide attempts, mostly with high life risk, are not related to depressive feelings but to emotional lability and impulsivity. In borderline patients, we find a quasi-permanent predisposition to suicide, seen as a structural attribute that becomes a favorable condition for reactive suicide attempts with a high degree of severity(14,26).
According to Oldham, 60-70% of borderline patients make suicide attempts, of which 10% are completed. In the same context, a variety of self-harming behaviors are described which, although often manipulative, are not premeditated, elaborated or controlled. Recurrent self-harming behavior is a way of managing dysphoric paroxysms and is maintained by a particular analgesia due to the release of endogenous opiates. In this way, the subject’s desire to die is not really reflected, but through this act, which is also a message addressed to those around, the tension and subjective suffering are reduced. This psycho-behavioral framework is in fact the tangible way in which borderline patients try to restore coherence to the structure of the individual self and to compensate for existential anxiety(26-29).
The complexity of the borderline structures and the diversity of comorbid conditions also explain the resistance to treatment, as well as the multitude of therapeutic strategies applied over time. The main purpose of therapeutic approaches is to reduce the risk of suicide. It is significantly increased in the case of the association of major depression, post-traumatic stress disorder, use and abuse of alcohol, or psychoactive substances. Loneliness, low socioeconomic status and poor educational status along with negative life events are also in the category of contributing factors(30,31).
It is important to differentiate between recurrent suicidal behavior and non-suicidal self-injury, both encountered in borderline personalities. In recent years, the frequency of non-suicidal self-injury has increased significantly, emerging as a new diagnostic entity in DSM-5, and not just one assigned to borderline structures. This confirms the complexity and extent of psycho-behavioral manifestations in the borderline spectrum that are favored by the dynamics and challenges of contemporary life. A dimensional approach allows understanding the phenomenon and ignoring the categorical diagnosis. The high values of neuroticism and introversion along with low values of conscientiousness prove to be prime risk factors for suicidal and/or self-harming behavior(32,33).
The anxious and depressive paroxysms that accompany the fate of borderline structures are largely an accentuated expression of some background features, and this fact explains the impulsiveness, hostility and aggression that often accompany them and that can have repercussions on the entourage(34).
In this sense, first of all, intrafamilial and couple relationships are disadvantaged, the insecurity of the attachment relationship being more pronounced in female patients. The dysfunctionality of interpersonal relationships is also maintained by the deficiencies of the autobiographical memory specific to borderline personalities; they simultaneously reflect the immaturity and diffusion of the Self(35-37).
The quality of life of patients with borderline personality disorder is largely dependent on its affective component. Thus, the presence of depressive symptoms always aggravates the quality of individual life measured with the Assessment of Quality of Life. Social and professional functioning, especially for women, is affected(38).
Any therapeutic approach to borderline patients remains a challenge due to the multitude of variables involved. Various therapeutic techniques are used, some with confirmed efficacy but whose way of action is insufficiently understood. The difficulties of interpersonal relationships maintained and the oscillations between idealization and rejection characteristic of borderline structures are the main obstacle against the initiation and stability of a therapeutic alliance(39).
Affective symptoms, suicide risk and self-control are particularly targeted. The present studies confirm the effectiveness of dialectical behavioral therapies and mentalization-based therapy in subjects with borderline personality disorder. According to neurobiological models, such as the reduced serotonergic reaction or the different binding potential of 5-HT2A receptors known to borderline structures, pharmacotherapeutic approaches have diversified in recent years and some psychotropic agents are proving useful. Selective serotonin reuptake inhibitors and mood stabilizers, such as carbamazepine, valproate or lamotrigine, are commonly used but with partial results. Second-generation antipsychotics, such as olanzapine, quetiapine or clozapine, may have beneficial effects on psychotic symptoms, impulsivity and on suicidal behavior with impaired functioning. However, an evidence-based psychopharmacological approach is currently lacking(40-42).
Given the severity of subjective suffering, the marked dysfunction in life roles, the impact on healthcare systems, the complexity and limitations of treatment and the high economic and social costs, the clinical and psychopathological framework focused on borderline personality also involves the mandatory involvement of the general practitioner in case management. It plays an important role in the early detection of risk factors arising from the social and economic status, family and professional environment of patients with borderline features. The general practitioner also has a major role in facilitating the collaboration with the primary social support network, the psychiatric team, in assisting comorbid conditions, crisis interventions and in strengthening the therapeutic alliance, each case requiring a strictly individualized approach.