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Motherhood and the 4 Symptom Domains of Borderline Personality Disorder

Mothers with borderline personality disorder (BPD) often have experienced early-life trauma, especially attachment trauma. BPD is a clinical challenge for several reasons and is associated with treatment-refractory depression and anxiety.

 Limited symptom improvement is often seen with psychotropic medications.

 Effective psychotherapy, such as dialectical behavioral therapy, is intensive, often expensive, and frequently difficult to access.

BPD symptoms can directly limit patients’ ability to consistently engage in treatment. Additionally, BPD is associated with prominent safety concerns, with self-harm behaviors common and seen in around 50% of patients.

 Patients with BPD often struggle with safety-interfering behaviors like substance use.

 BPD is associated with a high rate of completed suicide, commonly cited at up to 10%.

 Although there are limited data about how BPD symptoms shift over the life span, we know that as a complete diagnostic entity, it has low prospective diagnostic stability, cited at 37% in 1 study across a study period of 18 years.

 Some theorize a burnout over time, in which symptoms may become less prevalent with age, with the largest change seen after age 44.

Some studies describe a more nuanced life span process, wherein affective lability, relationship challenges, and impairments in sense of self persist, but impulsivity improves over time.

 Overall, little is known about fluctuations in symptoms and diagnosis across the reproductive period and in relation to the experience of motherhood.

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Mothers with borderline personality disorder often have experienced early-life trauma. How can you help?

Mothers With Borderline Personality Disorder Often Experience Trauma

Women adapting to their new roles as mothers can struggle with substantial mental health challenges. 

, for example, is widely understood as the most common condition faced by mothers after delivery. However, mothers can face many other overlooked psychiatric challenges across pregnancy, the postpartum period, and motherhood. 

(BPD) is a common diagnosis among young women that is highly understudied in pregnancy and motherhood.

Prevalence of BPD in the general population may be as high as 5.9%, around 10% in psychiatric outpatient clinics, and around 20% among psychiatric inpatients.

; around 87% of those receiving diagnoses are female. It is also thought to be associated with a higher degree of disability in women.

 Average age upon diagnosis is 24.8 years. Delayed diagnosis is common, often happening after an average of 3.6 years of treatment.

“Motherhood” is a broad construct involving constant change: pregnancy, postpartum, infancy, toddlerhood, school-age children, teenager, empty-nesting. We can consider 4 main domains of symptoms within BPD: identity/sense of self, impulsivity, relationship difficulties, and affective instability.

In the United States, the mean age of women at first birth is 26.9 years, which closely corresponds to the average age of women upon BPD diagnosis.

 By age 44 years, 85% of women in the United States have had at least 1 biological child, with an average of 2.1 children per woman.

 Based on these data, women with BPD are statistically likely to become mothers.

. In women with BPD, symptom severity has been associated with teenage pregnancy, unplanned pregnancy, and multiple prenatal adverse events.

In one study, women with BPD who presented for delivery were more likely to have used 

 or other addictive substances during pregnancy.

 Women with BPD have shown overall low rates of adherence to prenatal care and overall high likelihood of experiencing pregnancy as traumatic.

Women with BPD have also been found to be at substantially higher risk of preterm delivery than women in a hospitalwide control group; their infants were more likely to have low Apgar scores.

 During the postpartum period, 23.1% of women seeking psychiatric inpatient admission to a mother-baby unit in Australia met criteria for BPD.

 Another 11.1% showed significant BPD features without meeting full diagnostic criteria.

There have been substantially higher rates of reports made to child protective services—and a high rate of substantiation for those reports—for women with BPD compared with women without BPD.

 Another study found that persistent high levels of 

 in the mother across the first year postpartum was associated with externalizing problems in children when measured at 2.5 years postpartum,

 but this link was entirely associated with the presence of BPD symptoms in the mother.

Clinically, we see substantial symptom variability among women as they navigate motherhood, with some symptoms improving and others worsening. Although there is very little research addressing these symptom shifts directly, we can synthesize what we know from the literature and draw on clinical experience to examine how these symptoms are likely to change across the span of motherhood.

Personal identity is conceptualized through role commitments, a sense of inner agency, a world view that gives life meaning, and continuity across time. Motherhood has a profound impact on sense of self and can lead to a reevaluation of how autonomy, physical appearance, sexuality, and occupations influence these identities differently than they did prior to motherhood.

Shifts in how mothers understand themselves in relationship to others often begin with pregnancy.

 Socioculturally, intensive pressure is placed on mothers in Western societies to adopt “intensive parenting” practices that can squeeze out other important aspects of identity outside of motherhood.

 Cultural portrayals of motherhood emphasize fusion of a mother with her baby as the goal and the expectation.

In women with BPD, there are often clinical improvements in patients’ sense of self and a reduction in their experience of internal emptiness in their new role as mother. However, this initial stabilization is often brief. As children begin the process of individuation, mothers with BPD may experience it as a threat to their own sense of self, with subsequent heightened distress and symptomatology.

 There is also an increase in distress for these mothers as their grown children leave home, with substantial challenges in reestablishing a sense of self independent of the role they played as a mother caring for children living at home.

Impulsivity has a known negative impact on pregnancy. It is associated with a higher risk of unplanned pregnancy, risky sexual behaviors, and a risk for sexual victimization.

There is limited evidence that impulsivity increases during pregnancy and the postpartum period, although this notion is very understudied.

 Impulsivity in individuals with BPD commonly manifests in substance use disorders, with as many as 57% of individuals with BPD experiencing a 

 The negative impacts of substance use in pregnancy have been well documented.

Impulsivity is also associated with safety concerns, such as self-injurious behavior and risk for suicide.

 Impulsivity is also associated with eating, particularly binge eating, which can impact the health of women and their babies during pregnancy as well as body image during the postpartum period.

Evidence suggests that across the life span, impulsivity tends to become a less common symptom in BPD. However, certain kinds of impulsivity may increase during times of distress, and it is unclear how impulsivity changes in pregnancy and the postpartum period.

 For women in general, studies point to lower rates of self-harm during pregnancy.

The development of healthy relationships requires “theory of mind,” or the ability to understand our own internal state and that of others. Theory of mind includes cognitive and affective components, to understand others’ thoughts/beliefs and emotional states.

Connected regions of the brain that are active when we exercise this ability are referred to as the “theory of mind network.”

 Mothers make use of this ability, as they coregulate affect, when their baby is distressed and they mirror the baby’s distress to facilitate soothing.

During pregnancy, women experience changes in their brain architecture that likely strengthen their ability to care for and raise a child.

 These involve changes within the theory of mind network and have been shown to predict mother-baby attachment postpartum.

 These changes have the potential to impact women’s relationships with their larger community; their ability to draw support from their communities is associated with resilience to postpartum distress, whereas low support is a consistent risk factor in postpartum distress.

 Relationship distress, with increased conflict intensity, is common after the birth of children and women who lack support from a partner have a higher risk of developing and maintaining postpartum depression.

Relationships are particularly challenging for women with BPD. Adults with BPD have been shown to have significant deficits in theory of mind and often struggle to cooperate with others as a relationship progresses and to repair following a rupture in cooperation.

This makes women with BPD particularly vulnerable during the transition to motherhood and the postpartum period, when the ability to draw support from relationships is critical to maternal well-being. It also affects a mother’s ability to develop secure attachment with her baby, which is critical to child development. However, there is hope that the brain-based changes of motherhood might mitigate some of this risk or lend improvement in these areas.

Functional neuroimaging studies of patients with BPD have shown frontolimbic dysfunction that has a differential impact on negative emotionality and is consistent with clinical challenges around affective lability seen in adults with BPD.

Women with BPD struggle more with mood shifts in response to hormone fluctuations; that is, changes in ovarian hormone levels have been associated with fluctuations in negative emotionality and impulsivity in women with BPD. Fluctuations in hormone levels also characterize pregnancy and parturition, which may indicate that there is an increased risk in women with BPD for mood changes and symptom exacerbation during this period compared with women without BPD.

BPD traits vary individually over time and core traits of BPD can carry additional risk for distress as women transition to motherhood and parent young children. Additional research is needed to further understand the model of pathology for women with BPD as they enter motherhood and to determine strategies that can lead to resilience and health for mothers and their families.

 is a psychiatrist and regional medical director with

is director of women’s mental health at Houston Methodist Hospital in Texas.

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Clinical characteristics and mental health outcomes for women admitted to an Australian mother–baby unit: a focus on borderline personality disorder and emotional dysregulation?

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Borderline personality disorder is a common diagnosis among young women that is highly understudied in pregnancy and motherhood. Learn more here. 

Borderline personality disorder has many clinical features, including relatively unrecognized sleep disturbances. Generally, sleep problems are not considered a primary characteristic of this condition, but research is beginning to identify specific patterns of sleep disruptions that are associated with the disorder.

 is characterized by substantial emotional instability, relationship strains, behavioral problems, and difficulties with self-image. It is disruptive for the person who has the disorder, as well as for other individuals in their lives. There is no effective or recommended pharmacological treatment for this chronic disorder. The clinical management, which consists of behavioral and cognitive therapies, is challenging.

 differ from the criteria for diagnosis of bipolar disorder, there are some similarities, and it can be difficult at times to differentiate the 2 conditions.

 Bipolar disorder is a psychiatric disorder characterized by fluctuations in mood and energy levels, often with features of 

 and depression. Borderline personality disorder and bipolar disorder can both profoundly interfere with an affected patient’s quality of life, and they both often cause mood instability, hopelessness, and other overlapping symptoms. Unlike borderline personality disorder, 

 is often treated with prescription medication, along with counseling and behavioral therapy. A 

 of either of these disorders can delay proper referral to a psychiatrist or behavioral specialist and delay the timely implementation of appropriate therapy.

Several studies have shown that patients who have borderline personality disorder experience substantial variability in their sleep times from night to night when compared with the general population. These trends have been documented by clinical history and questionaries, and objectively with actigraphy and polysomnogram studies.

 is a disruptive condition that causes fluctuations in sleep rhythms, with phase delay and misaligned rest-activity pattens. Patients who have circadian rhythm sleep disturbance can experience irregular sleep patterns, with inconsistency and unpredictability from day to day. This causes a lack of adequate sleep, as well as low energy and concentration during the day. This sleep disturbance has been associated with borderline personality disorder.

Furthermore, the severity of certain symptoms of borderline personality disorder has been shown to correlate with certain actigraphy patterns that demonstrate daytime and nighttime abnormalities that are consistent with circadian sleep disturbance. In one study, patients who carried a diagnosis of borderline personality disorder and who had high levels of impulsivity and mood instability showed substantial phase delayed daytime activity patterns, low inter daily stability, weak amplitude, and greater fragmentation of rest activity states over a study duration of 28 days.

 These patterns were not noted in the study participants who had a diagnosis of 

 or in the controls. Another study showed that patients with borderline personality disorder had delayed phase of nighttime rest patterns, delayed daytime activity onset, as well as delayed temperature phase, while controls and patients who had bipolar disorder did not exhibit these features.

While there appears to be a correlation between the severity of symptoms of borderline personality disorder and circadian rhythm dysfunction, the clinical implications have not been established, nor has any specific cause-and-effect relationship. Whether the emotional and behavioral aspects of borderline personality disorder affect circadian rhythm regulation, or the circadian rhythm dysregulation affects symptoms of borderline personality disorder is not clear. The distinct differences in circadian rhythm disturbance patterns between patients with borderline personality disorder and patients with bipolar disorder that has been replicated in several studies is interesting, especially given the similarities between the 2 conditions.

Circadian rhythm disturbance is objectively quantifiable, but difficult to treat, and these observations do not clearly provide direction for the treatment of borderline personality disorder. However, awareness and treatment of sleep disturbances are important aspects of patient management. Screening tests, including interviews and actigraphy, can identify 

 that patients might not have otherwise reported if they did not know those problems were abnormal. Patients who would benefit from appropriate therapy for their sleep disorder may experience an improved quality of life if treatment is implemented. Furthermore, the diagnostic signs can potentially provide an adjunct in the diagnostic process for patients when borderline personality disorder is considered in the differential diagnosis. Because borderline personality disorder lacks objective criteria, it is possible that some patients may feel empowered, heard, and understood when they are made aware of an objective feature of their condition. This may potentially improve compliance with treatment for some patients.

; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder.

The emerging circadian phenotype of borderline personality disorder: mechanisms, opportunities and future directions.

3. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

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Circadian rest-activity patterns in bipolar disorder and borderline personality disorder.

Sleep disturbances in borderline personality disorder are relatively unrecognized. 

Sleep Patterns in Borderline Personality Disorder 

There are 13 million adults with borderline personality disorder (BPD) in the United States and, of that number, 1.5 million are adolescents, Carl Fleisher, MD, told attendees of the 2021 Annual 

 World CME Conference. To best support them, there are 3 things you need to do, added Fleisher, assistant clinical professor of psychiatry at University of California Los Angeles Health.

To kick off the discussion, Fleisher shared the case example of “Hannah,” a 16 year old girl who presents wondering if she has BPD after Googling her experience. Specifically, she has rapid mood swings, feels numb more often than sad, and cuts herself superficially several times a week. She has 1 friend and spends all of her time with that friend in fear the friend will desert her. She is interested in boys, but she avoids them. Hannah does not voice her needs to parents, teachers, or friend; instead, she goes along with whatever they want or like.

The first thing to do, therefore, is to make the diagnosis, Fleischer said. To do so, there are 9 criteria to consider, and sometimes it feels like they are all over the map. As such, the patient might not see the connections, so it is important to help draw them for patients. One way to do that, he explained, is to use a model of interpersonal hypersensitivity. Since we all want and need to be in relationships, and we are hypersensitive, we may have a fear of abandonment. From there, you can talk about the other symptoms.

 for rapid assessment of patients. It helps patients think things through, he explained. It also provides an opportunity for further discussion, as the clinician may have a different perspective than the patient does on a particular item.

Most patients are relieved when they finally receive a diagnosis, Fleischer said. He shared the following patient perspective: “It explained a lot of things and I felt an enormous sense of relief that there was an explanation for the way I was.”

The second thing is to refer to helpful resources, including psychoeducation, support, and treatment strategies, Fleisher said. He recommended a number of resources both for patients and their clinicians: the National Education Alliance for Borderline Personality Disorder, Mentalizing Initiative, the Anne Freud National Centre for Children and Families, and McLean’s Borderline Personality Disorder center.

In terms of treatments, there are 4 evidence-based psychotherapy modalities, Fleisher said. They include dialectical behavioral therapy, transference-focused psychotherapy, mentalizing-based therapy, and good psychiatric management, which is not an orientation but more of framework for clinicians. “It is also possible also that a plain old talk therapy is an adequate treatment for borderline personality disorder, especially if you have nothing else,” he told attendees.

It is also important to consider psychoeducation and family support, Fleischer added. He shared the results of a study looking at the impact of 6 weeks of psychoeducation on patients. The investigators found that symptoms reduced greatly—by about half—and stayed low for 2 months after the intervention protocol.

 Similarly, since caregivers and family members are under a lot of stress and strain, it is important to broaden the treatment lens and provide support to them, too.

Unfortunately, Fleischer noted there are no medications approved by the US Food and Drug Administration to specifically treat BPD. Likewise, there is no medication that is uniformly helpful. Too often, patients find themselves on multiple medications, he said, and polypharmacy poses a significant danger because of adverse effects, like weight gain associated with antipsychotics.

“We can do a whole hour-long talk on just medication for BPD, but the short of it would be: If you're going to use medication to treat one of the comorbid illnesses that BPD presents with, as opposed to this BPD itself, then you can try that,” Fleisher told attendees. “But if we're going to try to treat the symptoms of BPD itself like lability, paranoia, that sort of thing, then it may be that we want to consider a brief trial of medication to get people through a crisis.” After using the medications in a way that is helpful, it is important to consider taking it away, because we do not expect them to be helpful in the long-term and do not want to cause a problem of polypharmacy, he added.

The third thing to do is to monitor the effectiveness of the treatment, Fleischer said. Start with baseline measurements on the areas you and the patient want to address, be it self-harm, work performance, risky behaviors, and quality of life and relationships.

With these 3 things in mind, Fleisher concluded, clinicians can best support their patients with BPD. As he told attendees, “Borderline personality disorder is worth treating, and people with BPD are very rewarding to work with.”

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Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review.

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A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder

 2019;81(1):19m12753. Published 2019 Dec 31.

These 3 essential steps best support patients with borderline personality disorder, according to Carl Fleisher, MD. 

Borderline Personality Disorder: 3 Things You Need To Do for Patients

Tales From the Clinic: The Art of Psychiatry,

 we cover an intriguing case of dual substance use super-imposed on mood, anxiety, and trauma clinical picture. A significant challenge for this group of patients is the need for patient, methodical, consistent care to unravel the complex multifaceted triggers and perpetuating factors for continued maladaptive behaviors. The case description spans years of treatment and, while the details may seem sensational, they reflect the reality of what the addiction treatment clinic team encounters. In addition, there is much difficulty in hearing and processing patient accounts of trauma, which could lead to physician burnout.

“Ms Martin” is a 45-year-old female with bipolar disorder, generalized anxiety disorder, and suspected borderline personality disorder. She was transferred to the substance use disorders clinic by another psychiatrist after a diagnosis of opioid use disorder was obvious. At the time of her transfer, she was involved in prostitution to finance her roughly 25 tablets of acetaminophen and hydrocodone daily. Her opioid use disorder history had a protracted course, with her first exposure to prescription opioids at the age of 16 following a significant injury requiring surgical intervention. Her longest lifetime period of sobriety was 2 years.

Her immediate environment was not conducive to recovery, as she lived in a trailer with a male roommate who had mutual acquaintances that provided pain pills. In addition, Ms Martin engaged in sexual activity with the roommate in exchange for opioids. As time progressed, the relationship became physically abusive; she left after her roommate tried to hit her with a vacuum cleaner when she “didn’t do a good job cleaning the trailer.” At the time, she had been in treatment for 1 year, was started in medication-assisted therapy (MAT), and had been prescribed buprenorphine. She moved into an apartment with her mother, which greatly reduced access to opioids. She responded very well to MAT, with an absence of significant relapses as evidenced by the drug screenings during her monthly visits.

Three years into treatment, Ms Martin met a new boyfriend. Her urine drug screen (UDS) resulted positive for amphetamine. He provided her with substances that boosted her energy and aided in weight loss. She was not fully aware of what she was taking, but she thought it might have been amphetamine since it came in a “large jar with many capsules.” Testing verified the presence of methamphetamine.

These results were shared with Ms Martin, to her genuine surprise, and she expressed earnest motivation to stop methamphetamine use. Unfortunately, over the next year, she eventually met criteria for stimulant (methamphetamine) use disorder. This paralleled toxic developments in her relationship. She described a continued strong sexual attachment to her partner, and she remained intimate with him despite knowledge that he was simultaneously sexually active with her mother. She later bashfully admitted engaging in group intercourse with her partner and mother. During intercourse she described her partner’s derogatory and sadistic tendencies, which she felt she “deserved.”

Eventually, she developed disgust toward him. This resulted in an internal conflict because while she described feeling revolted by him, she simultaneously experienced severe loneliness and feelings of abandonment when he did not give her attention. This fueled further methamphetamine use as she wanted to be “skinny and pretty.”

The ongoing sexual relationship between her partner and mother resulted in significant tension within the apartment they all shared. On multiple occasions, Ms Martin described anxiety that her partner and mother were colluding against her. Methamphetamine use may have intensified these feelings. Although at times she expressed a desire to leave, she felt she had nowhere to go. Her partner contributed to paying bills, which further complicated her situation.

For the next year, Ms Martin continued to express significant ambivalence about her relationship. She recognized how the situation placed a strain on her relationship with her mother, yet she simultaneously feared the rejection, abandonment, and loneliness that would result from a breakup. She described symptoms of anxiety and sadness when away from her partner, and he was using methamphetamine pills as a tool to control her. She compared her “love-hate” relationship with her significant other with that of her relationship with the methamphetamine pills.

In addition to work in building Ms Martin’s feelings of self-worth and autonomy, a motivational interviewing style was utilized to help her resolve some of her ambivalence toward the relationship. Although she voiced much more change talk to end the relationship, compared to sustain talk, she had difficulty committing to ending the relationship.

Due to the alarming rate of opioid overdoses secondary to fentanyl, clinicians and those struggling with substance use are becoming aware that the product purchased is not always as marketed. Anecdotal reports of increasing concomitant opioid and amphetamine use abound, but the condition is not well understood, nor systematically studied. In the case of this patient, confirmatory test showed methamphetamine, whereas she believed she was getting amphetamine or methylphenidate; she may have inadvertently gained access to a supply of methamphetamine.

Currently, there are no US Food and Drug Administration-approved treatments for methamphetamine use disorder. Some studies suggest the use of bupropion, naltrexone, and mirtazapine may have some limited efficacy in 

 In addition to treating Ms Martin’s SUD, the team addressed co-occurring mood and anxiety symptoms (she had witnessed her brother injured in a car accident). Her initial regimen included duloxetine and aripiprazole for depression, anxiety, and mood stabilization. Bupropion was not tried due to her concern of its risk of exacerbating her anxiety, and she declined mirtazapine due to its risk of weight gain because she already struggled with her body image. After Ms Martin expressed concerns that aripiprazole may be contributing to her weight gain, she was switched to cariprazine with the perceived potential benefit of weight-neutrality, since a desire for weight loss was a contributing factor to continued methamphetamine use. Another potential benefit of cariprazine includes preliminary interest in the D3 receptor affecting addictive behaviors.

A patient presents with multiple substance use disorders super-imposed on mood and anxiety disorders. Where does a clinician even begin?

Borderline Personality

Mothers With Borderline Personality Disorder Often Experience Trauma

Motherhood and the 4 Symptom Domains of Borderline Personality Disorder

Sleep Patterns in Borderline Personality Disorder

Borderline Personality Disorder: 3 Things You Need To Do for Patients

I Had to Use

Mini Quiz: Neurobiology of Borderline Personality Disorder

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