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Introduction

Borderline Personality Disorder (BPD), also known as Emotionally Unstable Personality Disorder (EUPD), is a complex psychiatric disorder, characterised by dichotomous thinking, extreme emotional instability and mood swings, intense persistent fear of abandonment and interpersonal relationship difficulties.  Women and men are equally affected by BPD, but symptomology can present more strongly in women (1).

Background

There is much debate regarding BPD, and diagnosis can depend greatly upon the physician who is seen. Sometimes BPD can be misdiagnosed in place of PTSD, as both conditions share some common symptomology. Furthermore, autism may also be misdiagnosed as BPD in some cases, due to the way autism manifests differently in women and some of the social and emotional overlap between the two conditions (2) (3).  Treatment offered may involve DBT, mentalisation therapy group therapy and art therapy offerings. In the UK, there are no medications currently licensed to treat BPD specifically (4).

Symptoms

Symptoms may include (5) (6):

  • self-harm
  • suicidal ideation and intent
  • paracusia (hearing voices)
  • shifts in perception of self and states of consciousness (depersonalisation and dissociation)
  • amnesia
  • phobic avoidance of traumatic experiences

Causes

Complex Trauma

There has been much debate and controversy regarding the labels BPD and EUPD. This is because women are more commonly diagnosed than men, and the majority of individuals diagnosed have survived serious trauma, such as physical, sexual, psychological and emotional abuse, particularly during childhood. Many individuals with BPD either witnessed or experienced domestic abuse as children or adults (7) (8). Emotional abuse in childhood has been particularly strongly assosciated with BPD development (9). Childhood abuse has been suggested to be present in the personal histories, as 90% of all individuals who are diagnosed with BPD (10).Dr Jessica Taylor, CEO at Victim Focus, forensic psychologist specialising in advocacy for female survivors of violence and abuse and author of the book, “Why Women are Blamed for Everything”  argues that BPD is an invention which pathologises and stigmatises female abuse survivors and serves to let perpetrators off the hook, in terms of their moral responsibility to answer for their crimes. This has been argued due to the prevalence of abuse and adverse childhood experiences in the histories of individuals who are given the diagnosis. Dr Taylor advocates that it is more appropriate to diagnose individuals with C-PTSD (complex post traumatic stress) rather than BPD (11).

Chronic Stress

BPD is characterized biochemically by stress-induced disruptions to the HPA axis, which results in cortisol release and impacts on the hippocampus, amygdala and prefrontal cortex regions of the brain. When grey matter is chronically overstimulated, this is involved in permanent neuromorphological changes, which can be perceived in fMRI scans (12).

Gut Brain Axis Disruption

Women with BPD have been demonstrated to have lower levels of oxytocin, which is essential for affiliation and social interaction (13). There has been hypothesised to be a correlation between oxytocin levels and bacterial strains in the gut microbiota, namely Lactobacillus reuteri (14). Lactobacilli strains of bacteria are essential for the synthesis of the neurotransmitter Gamma aminobutyrate (GABA), which exerts a calming effect on the brain and is required for emotional stability (15). BPD has additionally been associated with disruptions in attachment style, most notably when there has been abuse and neglect from a primary caregiver. This may be explanatory as to the key distinguishing features of BPD, which includes fear of abandonment and difficulties forming and maintaining relationships with others (16) (17). There may logically be an association between levels of oxytocin and these observed disruptions in attachment styles.

Hormonal Imbalance

Fluctuations in levels of oestrogen (17β-estradiol or E2) and progesterone (P4) have also been observed in BPD, particularly with relation to symptom severity of emotion and cognition.  This may account for the hypothesised increased severity of symptoms observed in females compared with males (1).

Nutrition & Lifestyle Interventions

Research has implicated several nutrient deficiencies as being present in individuals with BPD. Interestingly, women with BPD have been indicated to be at higher risk of developing bone disorders, such as osteoporosis, which may also be relevant in terms of many of these nutrient deficiencies (18).

Vitamin D

Suicidal behaviour can be a key feature of borderline personality disorder. Although research into Vitamin D and BPD specifically is lacking, it is interesting to note that Vitamin D levels have been observed to be significantly lower in individuals who are suicidal (19). It has therefore been suggested that individuals who are suicidal should be tested for Vitamin D deficiency and receive supplementation of the nutrient should deficiency be established (19). In terms of whether this would translate to a reduction in symptoms and incidences of suicidal behaviour requires further investigation by large scale research. 

Key Actions for Increasing Vitamin D

  • Increase foods containing Vitamin D, including:  oily fish, eggs, dairy products and mushrooms
  • Ensure safe and adequate sunlight exposure 

Side effects: weakness, dry mouth, nausea, vomiting, and others. 

Contraindications with medication: Vitamin D interacts with several medications, including weight loss and heart medications.

Magnesium

Lower levels of magnesium have been observed in individuals with BPD (20). Further, supplementation of magnesium, in conjunction with vitamin B6, has been indicated to be supportive for reducing symptoms in individuals with BPD (20). This is an area that is otherwise to date largely under researched and would merit from further investigation.

Key Actions for Increasing Magnesium

Ensure you are consuming foods that are rich in  magnesium like almonds, spinach, pumpkin seeds, and cashews. 

Side effects: High doses of magnesium from supplements or medications can cause nausea, abdominal cramping and diarrhoea.

Contraindications with medication: magnesium in supplements can interact with some types of antibiotics and other medicines.

Omega 3

Some evidence has indicated that omega 3 may help to reduce the severity of symptoms on women with BPD (21), particularly with relation to impulsivity. Omega 3 has also been suggested to be beneficial in conjunction with valproic acid (22), with beneficial effects continuing to be observed following cessation of supplementation in a follow up study, particularly for outbursts of anger (23). Moreover, a further study indicated that omega 3 supplementation, in the form of EPA, was beneficial for reducing symptoms of aggression in women with BPD (24).

Eat oily fish, such as salmon, mackerel and sardines, at least twice a week, and seeds, such as flaxseeds (also called linseeds) and chia seeds, on most days. Furthermore, supplement omega 3 through fish oil or a vegan alternative. Look for a supplement that contains both EPA and DHA.

The best fish for EPA, the type of omega 3 fat that’s been most thoroughly researched are: mackerel (1,400mg per 100g/3oz), herring/kipper (1,000mg), sardines (1,000mg), fresh (not tinned) tuna (900mg), anchovy (900mg), salmon(800mg), trout (500mg). Tuna, being high in mercury, is best avoided in autism due to heavy metal considerations.

The best seeds are flax seeds and chia seeds. Flax seeds are so small they are best ground and sprinkled on cereal. Alternatively, use flaxseed oil, for example in salad dressings. While technically providing omega 3 only about 5% of the type of omega 3 (alpha linolenic acid) in these seeds is converted in your body into EPA. Therefore individuals who are following a plant based diet may benefit from supplementing with vegan omega 3 supplements.

Side effects: Causes loose stools in sensitive individuals if they are started on too high a dose.

Contraindications with medication: Essential fats may have a ‘blood-thinning’ effect and should not be mixed with ‘blood thinning’ medication, such as warfarin or heparin. Always consult your doctor before commencing a new supplement.

Disclaimer: Always discuss with your doctor before beginning any supplements

References

  1. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., Smith, S. M., Dawson, D. A., Pulay, A. J., Pickering, R. P., & Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry, 69(4), 533–545. https://doi.org/10.4088/jcp.v69n0404
  2. Ford, J. D., & Courtois, C. A. (2014). Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline personality disorder and emotion dysregulation, 1, 9. https://doi.org/10.1186/2051-6673-1-9
  3. Dudas, R. B., Lovejoy, C., Cassidy, S., Allison, C., Smith, P., & Baron-Cohen, S. (2017). The overlap between autistic spectrum conditions and borderline personality disorder. PloS one, 12(9), e0184447. https://doi.org/10.1371/journal.pone.0184447
  4. NHS, 2022. Available at: https://www.nhs.uk/mental-health/conditions/borderline-personality-disorder/treatment/
  5. Brown, R. C., Plener, P. L., Groen, G., Neff, D., Bonenberger, M., & Abler, B. (2017). Differential Neural Processing of Social Exclusion and Inclusion in Adolescents with Non-Suicidal Self-Injury and Young Adults with Borderline Personality Disorder. Frontiers in psychiatry, 8, 267. https://doi.org/10.3389/fpsyt.2017.00267
  6. MacIntosh, H. B., Godbout, N., & Dubash, N. (2015). Borderline personality disorder: Disorder of trauma or personality, a review of the empirical literature. Canadian Psychology / Psychologie canadienne, 56(2), 227–241. https://doi.org/10.1037/cap0000028
  7. de Aquino Ferreira, L. F., Queiroz Pereira, F. H., Neri Benevides, A., & Aguiar Melo, M. C. (2018). Borderline personality disorder and sexual abuse: A systematic review. Psychiatry research, 262, 70–77. https://doi.org/10.1016/j.psychres.2018.01.043
  8. Mainali, P., Rai, T., & Rutkofsky, I. H. (2020). From Child Abuse to Developing Borderline Personality Disorder Into Adulthood: Exploring the Neuromorphological and Epigenetic Pathway. Cureus, 12(7), e9474. https://doi.org/10.7759/cureus.9474
  9. Kuo, J. R., Khoury, J. E., Metcalfe, R., Fitzpatrick, S., & Goodwill, A. (2015). An examination of the relationship between childhood emotional abuse and borderline personality disorder features: the role of difficulties with emotion regulation. Child abuse & neglect, 39, 147–155. https://doi.org/10.1016/j.chiabu.2014.08.008
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  11. Taylor, Dr J. 2020. Why Women are Blamed for Everything. Hachette.
  12. Mainali, P., Rai, T., & Rutkofsky, I. H. (2020). From Child Abuse to Developing Borderline Personality Disorder Into Adulthood: Exploring the Neuromorphological and Epigenetic Pathway. Cureus, 12(7), e9474. https://doi.org/10.7759/cureus.9474
  13. Bertsch, K., Gamer, M., Schmidt, B., Schmidinger, I., Walther, S., Kästel, T., Schnell, K., Büchel, C., Domes, G., & Herpertz, S. C. (2013). Oxytocin and reduction of social threat hypersensitivity in women with borderline personality disorder. The American journal of psychiatry, 170(10), 1169–1177. https://doi.org/10.1176/appi.ajp.2013.13020263
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  15. Grover, S., Patil, A., Kaur, A., & Garg, G. (2019). Probiotics: A Potential Immunotherapeutic Approach for the Treatment of Schizophrenia. Journal of pharmacy & bioallied sciences, 11(4), 321–327. https://doi.org/10.4103/jpbs.JPBS_47_19
  16. Aaronson, C. J., Bender, D. S., Skodol, A. E., & Gunderson, J. G. (2006). Comparison of attachment styles in borderline personality disorder and obsessive-compulsive personality disorder. The Psychiatric quarterly, 77(1), 69–80. https://doi.org/10.1007/s11126-006-7962-x
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  19. Grudet, C., Malm, J., Westrin, A., & Brundin, L. (2014). Suicidal patients are deficient in vitamin D, associated with a pro-inflammatory status in the blood. Psychoneuroendocrinology, 50, 210–219. https://doi.org/10.1016/j.psyneuen.2014.08.016
  20. Kopitsyna, U. E., Grishina, T. R., Torshin, I. Y., Kalacheva, A. G., & Gromova, O. A. (2015). Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova, 115(11), 85–96. https://doi.org/10.17116/jnevro201511511185-96
  21. Karaszewska, D. M., Ingenhoven, T., & Mocking, R. (2021). Marine Omega-3 Fatty Acid Supplementation for Borderline Personality Disorder: A Meta-Analysis. The Journal of clinical psychiatry, 82(3), 20r13613. https://doi.org/10.4088/JCP.20r13613
  22. Bellino, S., Bozzatello, P., Rocca, G., & Bogetto, F. (2014). Efficacy of omega-3 fatty acids in the treatment of borderline personality disorder: a study of the association with valproic acid. Journal of psychopharmacology (Oxford, England), 28(2), 125–132. https://doi.org/10.1177/0269881113510072
  23. Bozzatello, P., Rocca, P., & Bellino, S. (2018). Combination of Omega-3 Fatty Acids and Valproic Acid in Treatment of Borderline Personality Disorder: A Follow-Up Study. Clinical drug investigation, 38(4), 367–372. https://doi.org/10.1007/s40261-017-0617-x
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