Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

Jillian Pratzner
The Neurobiology of Borderline Personality Disorder
December 3, 2014
Naropa University
Clinical Neuroscience

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

Abstract
This research paper takes an in-depth look at the neurobiological causes of borderline personality
disorder (BPD) symptoms. There have been numerous studies showcasing abnormalities in the
insula, amygdala, hippocampus, and anterior cingulate cortex in the BPD patients brain. These
abnormalities create emotional dsyregulation and limbic hyperarousal, making it difficult for the
BPD patient to create secure attachments due to their erratic social behavior. There is a high rate
of substance use among people with BPD, especially with opiates, that could point to a
dysfunction in the endogenous opioid system (EOS) as well. Evidence shows that the BPD brain
interprets negative and neutral information as negative, and that they even rate positive relational
experiences as negative. This correlates with their high rates of anxious and fearful attachment
patterns and tendency to view people with suspicion. There is a powerful genetic component to
the etiology of the disorder, and those with BPD report high levels of abuse in their childhood,
however the self-report of the BPD patient should be viewed with caution due to their bias
towards the negative. BPD patients find it extremely difficult to concentrate on a task when
emotional pictures are presented, again leading to the conclusion of a hyper-aroused limbic
system. There are also high rates of self-harm within the community. In a study examined in the
following paper, it was found that BPD patients regulate themselves with pain and that they were
able to withstand high heat temperatures and even find it euphoric. This again points to the
theory that there could be a dysfunction in the EOS system. It is important when treating the
BPD client to recognize when they are triggered and to teach affect regulation strategies.
Therapies such as Mentalization (MBT), Dialectical Behavior Therapy (DBT) and mindfulness
are often advocated for the treatment of BPD.

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

Borderline Personality Disorder (or BPD) is a debilitating condition that impairs a
persons ability to function in society and maintain relationships. The severe disorder affects
between 1-6% of the general population (e.g., Ancona et al., 2014; Grant et al., 2008). BDP is
distinguished by,
distressing, impairing, and pervasive dysregulation of: (1) affect (chronic fear of
abandonment, affective instability, intense and inappropriate anger), (2) of selfconcept and attention (dissociative experience), of cognition (distorted thoughts and
perceptions), (3) of interpersonal relationships (intense, volatile), and (4) of behavior
(impulsivity and repetitive self-destructive behaviors). Individuals with BPD often
engage in self-injurious and suicidal behavior, gambling, compulsive shopping,
substance or alcohol use, binge eating, and reckless driving (American Psychiatric
Association, as cited in Barone, Fossati, Guiducci, 2011, p. 452).
Co-morbidity is oftentimes present with BPD, which leads to wide variation in research methods
and subjects. Most commonly bipolar disorder, mood and anxiety disorders, and narcissistic and
schizotypal personality disorders are linked with BPD (Grant et al., 2008). It is reported that up
to 75% of patients with BPD also have substance abuse problems (Hatzitaskos, Soldatos,
Kokkevi, & Stefanis, 1999), and 45% of heroin addicts have BPD (Darke, Ross, Williamson, &
Teesson, 2005). It is important to note that the erratic behavior of those with BPD can be better
understood once the overwhelming neurobiological functions of the disorder that override free
will in the individual, are realized (Ancona et al., 2014). The neurobiology, attachment patterns,
affect regulation, self-harming behavior and possible treatments for BPD will be investigated in
this review.
Neurobiology of BPD
Intense mood swings alternating between dysphoria and euphoria are a commonly
reported by those with BPD (Ancona et al., 2014). These changes in mood, which may last only
a few hours, are often independent of positive or stressful precipitating events but occur more or
less out of the blue, which is why BPD patients are often characterized as unpredictable, hot-

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

tempered, or moody (Ancona et al., 2014). Neurobiological findings suggest that prefrontal
regulation dysfunction and limbic hyperarousal in BPD explain this affective instability (Bohus
et al., 2012). MRI studies have shown volume reduction of cerebral regions associated with
affective regulation, such as the hippocampus, amygdala, and anterior cingulate cortex (ACC)
(e.g., Cho, Han, Lyoo, 1998; Elst, et al., 2003), as well as hyperactivation in the insula (Fan,
Minzenberg, New, Siever, Tang, 2007).
In a study conducted by Ancona et al., (2014), 25 female patients with BPD from an
outpatient clinic were compared to control subjects using T1-weighted structural MR images. All
patients were receiving psychiatric care at the time and were taking at least one medication.
Patients who fulfilled diagnostic criteria besides BPD were excluded. The study aimed to
replicate findings of abnormalities within the fronto-limbic network, such as the ACC,
orbitofrontal cortex (OFC), dorsolateral prefrontal cortex, and amygdala- hippocampus complex
(Ancona et al., 2014, p. 34), that are thought to be present in BPD pathophysiology. The study
showed abnormalities of limbic structures in both the right and left hemispheres in BPD
patients (Ancona et al., 2014, p.37) and,
revealed significant morphological abnormalities of cortical thickness, volume, mean
curvature, metric distortion, surface area, and depth of sulcus in such areas among BPD
patients. These findings are in agreement with previous structural neuroimaging studies
involving BPD patients, and highlight the involvement of these areas in the regulation of
mood reactivity, impulsivity, and social behavior, which are considered dysfunctional in
these patients (Ancona et al., 2014, p. 37).
Although the study was limited in terms of gender and the number of patients, the findings
correlate with current research into the neurobiology of BPD and offer an explanation as to why
those with BPD act as they do.
Possible Implications of a Dsyregulation of the Endogenous Opioid system

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

Current research (Bandelow, B., Falkai, P., Schmahl, C., Wedekind, D.,
2010) looks into the correlation between a dysregulation of the endogenous
opioid system (EOS) and borderline personality disorder. All individuals want to
stimulate their reward system, but healthy humans impose certain limits on themselves and
prefer to satisfy their instinctual needs such as sex and food in a controlled way, so as to not to
break social rules or to avoid dangerous situations (Bandelow et al., 2010, p. 631).Bandelow
et al. (2010) links several key behaviors of BPD to an attempt at activating
the EOS system, however states that no evidence supports this as strongly
as the high rate of substance abuse, particularly with opioids, in BPD.
Bandelow et al. (2010) states,
theEOSandtherewardsystemarecloselylinkedandhaveaninverserelationship,the
primarydysfunctionmayalsolieinadisturbanceofdopaminereceptorsinthe
mesolimbicdopaminesystem,adecreaseddopaminerelease,oradisturbedconnectivity
betweentheEOSandtherewardsystem.However,aprimarydisturbanceofthe
dopaminergicrewardsystemislesslikely,aspatientswithBPDdonothaveapreference
fordopamineagonistsorantagonists,whereastheyhaveaclearpreferenceforsubstances
affectingtheEOS(p.126).
Bandelowetal.(2010)attributesallofthedesperateanddisturbingsymptomsofBPDtoan
attemptatachievingintheshortestamountoftime,abaselinelevelofendorphins.Forinstance,
patientswithBPDinduceasurvivalstateinthebodywhentheycutthemselvesthatcouldbe
seenasawaytogenerateanendorphinsrush,andcouldexplainwhytheyfeeleuphoriaas
opposedtopain(Bandelowetal.,2010).TheevidencethatadsyregualtionoftheEOSis
responsiblefortherisky,thrillseekingbehaviorsofthosewithBPDiscompellingandmerits
morescientificresearch.
AttachmentandBPD

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

Those with borderline personality disorder are generally known to exhibit a strong
association with unresolved/fearful attachment as well as preoccupied attachment, and to be
unable to sustain secure attachment (e.g., Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004;
Levy, Beeney, & Temes, 2011). Attachment dysregulation in BPD is often linked to hyperactivity
of the attachment system and associated with attempts to frantically avoid abandonment and seek
relief and support as well as exaggerate the seriousness of threats and expect hostility from
others, often expressed through clingy, hot and cold behavior (e.g., Fonagy, Luyten, Strathearn,
2011; Fonagy & Bateman, 2008). This dsyregulation accounts for the diagnostic unstable and
intense pattern of interpersonal relationships, and a characteristic rapidly escalating tempo
moving from acquaintance to great intimacy over extremely brief time periods (Fonagy et al.,
2011, p. 49). A study by Barone, Fossati, & Guiducci (2011) looked at attachment patterns of
four subgroups within BPD and found the following:
The Enmeshed-Preoccupied attachment pattern (i.e., E classifications) was the most
frequently observed pattern among BPD participants with Mood/Anxiety Disorders
(60%), whereas the Dismissing/Derogating pattern (i.e., Ds classifications) was the most
frequently observed in the Substance Abuse/Dependence (58%), Alcohol
Abuse/Dependence (55.0%), and Eating Disorders (60.0%) (p. 458-459).
Within secure attachment relaxation of interpersonal caution is needed in order to create
closeness, as represented in the expression love is blind, and without this relaxation
neurocognitive systems are likely to generate interpersonal suspicion (Fonagy et al., 2011, p.
54). Interestingly, oxytocin is linked to reduction of neuroendocrine responses to social stress,
allowing animals to facilitate approach behavior and override defensive behavior. However,
increasing levels of norepinephrine and dopamine interact such that above a certain threshold,
the balance shifts from prefrontal executive functioning to amygdala-mediated memory encoding
and posterior-subcortical automatic responding (fightflightfreeze) (Fonagy et al., 2011, p.

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

55). This response could help account for avoidant and fearful attachment strategies employed by
those with BPD.
Etiology and Adolescence
Borderline personality disorder has been related to genetic factors,
with a twin study accounting 69% of variance to genetics (Torgersen et al., 2000). However
if the parents of BPD patients also had symptoms of the disorder, there is a higher chance that
they had limited childrearing abilities, possibly because of substance abuse, frequent absence as
a result of hospitalizations, unfavorable family and social environment conditions, or a tendency
toward sexual deviations (Bandelow et al., 2010, p. 2). Those with BPD have been shown to
report higher rates of trauma and childhood sexual abuse (e.g., Ludolph et al., 1990; Paris,
Zweig-Frank, & Guzder, 1994), however twenty to forty-five percent of BPD patients report no
history of sexual abuse, and 80% of individuals with sexual abuse have no personality
pathology (Goodman & Yehuda, 2002, as cited in Bandelow et al., 2010, p. 2). In a study by
Cho, Essex, Kalin, & Cho (2002) maternal stress exposure from the ages of birth to four and a
half years was shown to sensitize childrens pituitary-adrenal responses, which could account for
a stressful family environment leading to a predisposition to BPD. Most patients with BPD
described their early home life as unhappy and disadvantaged, and parental relationships as
fraught with rejection and misunderstanding (Barone et al., 2011). However these reports could
also be explained by these patients contradictory and malevolent internal representations of
caregivers, a finding consistent with patients retrospective self-reports (Carbone, Kim, Sharp,
2014, p. 126). The tendency for BPD patients to misinterpret others neutral and positive attempts
at closeness will be explored later on.

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

The unique and distinctive features of BDP are shown to emerge in adolescence (Sharp &
Bleiberg, 2007). One study by Carbone, Kim and Sharp (2014) looked at the correlation between
parental attachment security and negative or positive regulation strategies employed by
adolescents with BPD. It was found that elevated features of BPD intensified negative regulation
strategies regardless of protective factors, and that lack of attachment security did somewhat
limit opportunities to learn positive regulation strategies but ultimately that attachment insecurity
did not lead one to adopt negative strategies as had been assumed. However the study did make
one remarkable discovery:
In our data, adolescents paternal attachment produced larger and more consistent
associations with our variables of interest than maternal attachment. We did not expect
this difference, and this result is therefore considered preliminarySpecifically, the
moderating role of negative regulation strategies on the link between paternal
attachment and BPD was found to be specific to girls. This may underscore a particularly
deleterious role that negative regulation strategies play in immobilizing adaptive
capacities that adolescent girls develop in the context of their relationship with their
father (Carbone et al., 2014, p.132)
Paternal attachment in adolescence has been linked to the childs management of affect in goal
directed behaviors and mastery and exploration of the environment (Grossmann et al., 2008).
Although this discovery is fascinating and could contain many implications, it has not been
replicated and deserves further research.
Romantic Relationships
Romantic relationships of BPD patients are characterized by nearness-distance
conflicts, or the phenomenon splitting which accounts for idealization and devaluation of close
people and the sudden dissolution of relationships (Bandelow et al., 2010). A study by Bhatia,
Burckell, Davila, Eubanks-Carter (2013) tested the hypothesis that BPD features affect
appraisals of daily romantic relationship experiences (DREs), such that they are perceived more
negatively (p.518) Previous research has shown that BPD individuals are more likely to rate

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

neutral faces as more rejecting (e.g., Meyer, Pilkonis, & Beevers, 2004). In the study (Bhatia et
al., 2013) males reported greater loss and,
as predicted, BPD features were associated with appraising partner-initiated negative and
positive DREs negatively. Greater BPD features were associated with reporting greater
negative impact and greater emotional loss in response to these DREs. In response to
self-initiated negative DREs, BPD features were not associated with reporting greater
negative impact, although they were associated with reporting greater emotional loss.
Although speculative, it is possible that participants interpreted the rating questions such
that there was a distinction between the DRE impacting them personally (negative
impact) versus their relationship (emotional loss) (p.520).
Women reported greater shame even in the appraisal of positive DREs, which could be
connected to a core belief that they dont deserve good things because they are bad. It is
interesting that in both sexes even positive DREs are seen as stressors. This could be one
interpretation of why those with BPD self-report greater interpersonal stress within relationships.
Attention & Affect Regulation
Working memory is crucial to maintaining goal-directed behavior in the face of
emotional stimuli; this ability has been shown to be impaired in those with BPD (e.g., Banich et
al., 2009). In a study by Bohus et al. (2012) BPD patients were instructed to keep
specific information in mind across an interval of time in which neutral or
emotional distractors were presented: a test known as the Emotional
Working Memory Task (EWMT). The findings of the study (Bohus et al., 2012)
suggested reduced information flow between the working memory centers of the
brain and the amygdala.
Compared to HC, BPD patients showed a stronger coupling of the amygdala with right
dmPFC (medial frontal gyrus). Moreover, reaction times positively predicted amygdala
connectivity with right dmPFC (medial frontal gyrus) and right dlPFC (middle frontal
gyrus) during emotional interference in the BPD group. This means, a stronger positive
coupling of the amygdala with dorsomedial and dorsolateral prefrontal regions was
associated with more working memory impairments after emotional distraction in BPD
patientsWhile patients showed positive amygdala with right dmPFC and left dlPFC, HC

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

showed negative amygdala connectivity (suggesting inhibitory interactions) with these
regions (Bohus et al., 2012, p. 12).
It was also presented that even neutral distractors produced positive amygdala connectivity with
the right lingual gyrus; an effect that healthy controls did not replicate. These findings further
validate the research that neutral stimuli is enhanced in affective evaluations of those with BPD.
All in all the findings by Bohus et al., (2012) reflected the difficulties of men and women with
BPD in shifting attention away from emotional information that is seen to pertain to themselves,
in order to maintain focus on the task at hand.
Self-Harming Behavior
Self-harming, mutilation and suicide are prevalent symptoms in BPD. Self-harm is thought
to have a population of 21% in clinical populations (Briere and Gil, 1998) and 89% in those
diagnosed with BPD (Zanarini et al., 2008). Self-harmers are more likely to commit suicide and
between 5 to 10% of BPD patients commit suicide (Halfon,Laget,&Barrie,1995).Acomplex
neurobiologicalmechanismcouldberesponsibleforthesehighratesofselfharminBPD.On
onelevel,selfharmaccomplishesanattentionalshiftawayfromemotionalpainthatcouldbe
compensatingfortheprefrontalcortexslackofattentionalcontrol(Bohusetal.,2014).Ina
studybyBohusetal.,(2014)BPDpatientsandhealthycontrols(HC)wereshownnegativeand
neutralpictureswhilebeinginducedwithvaryinglevelsofheat.WhereasHCsshowednegative
connectivitybetweenthelimbicandprefrontalareaswhenwarmtemperaturewascombinedwith
negativepictures,BPDpatientsonlypresentedthenegativeconnectionwhennegativepictures
werecombinedwithpainfulheat.Thefindingsofthestudy(Bohusetal.,214)alsodemonstrated
thatinBPDpatientstheparalimbicsystemrespondedwithhyperactivityinresponsetoboth
neutralandnegativepictures,furtheraccentuatingpreviousresearch.Bandelowetal.,(2010)

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

makesaninterestingobservationthatalthough,
patientswithBPDseemtohavereducedpainduringselfinjury,theyseemtohavereduced
paintolerancewhensufferingfromheadache,toothache,orotherformsofnonself
inflictedpain,astheyrequirehigherdosesofpainmedicationsthanarenormallyused
(Saper&Lake,2002).Thisseemsparadoxical,butthedifferencebetweenthesesourcesof
painandcuttingorburningwoundsisthatheadacheandtoothachearenotassociatedwith
tissuedamageasisthecasewithbleeding,whichseemstobeaprerequisiteforendorphin
release.(p.629)
Treatment and Conclusion
Oftentimes polypharmacy is employed in the treatment of BPD, with antipsychotics,
hypnotics, antihistamines, and mood stabilizers frequently utilized (Wedekind,Bandelow,&
Ruther,2005).Naltrexone,anopioidantagonist,isadministeredtocontrolselfharmingbehavior
asitblockstheeffectsofendorphinrelease(Bandelowetal.,2010).Howeverthefulleffectsof
naltrexonearenotyetunderstoodandfurtherresearchintotheefficiencyofthedrugshouldbe
considered. With regard to therapies Mentalization (MBT), Dialectical Behavior Therapy (DBT)
and mindfulness are common approaches to working with BPD (e.g., Carbone et al., 2014;
Bohus et al., 2014). All therapies work to expand higher cortical areas of the
brain and allow for different choices of behavior. Fonagy et al. (2011)
suggests that in regard to therapy
there should be (a) a de-emphasis of deep, unconscious interpretations in favor of
conscious or near-conscious content; (b) a modification of therapeutic aim, especially
with severely disturbed patients, from insight to recovery of mentalization (i.e., achieving
representational coherence and integration); (c) careful eschewing of descriptions of
complex mental states (conflict, ambivalence, unconscious) that are incomprehensible to
a person whose mentalizing is vulnerable; (d) avoidance of extensive discussion of past
trauma, except in the context of reflecting on current perceptions of mental states of
maltreating figures and changes in mental state from being a victim in the past versus
ones experiences now (p. 57).
It seems particularly important to refrain from provoking emotional arousal in the BPD client
while simultaneously working on strategies for regulating affective states. There might be a

Running head: THE NEUROBIOLOGY OF BODERLINE PERSONALITY DISORDER

strong chance that the BPD client would become triggered at some point in the therapeutic
relationship and direct hostility at the therapist. In that case it would be a prime opportunity to
model emotional regulation and offer the client a safe space to repair the relationship and
experience the positive feelings associated with a trusting, secure attachment.
Borderline personality disorder is a disabling condition that affects both the mind and
emotions of those who have it as well as their social relationships. As we are social creatures
who need contact with other humans, one can imagine how alienating it would be to feel
excluded and suspicious of all other humans. This might be why those with BPD feel it necessary
to cling on to the relationships they do have and at any means, even provoking negative attention
as opposed to no attention. There is obvious dsyregulation among the emotional limbic system of
the brain and a discord between that system and the pre-frontal cortex where decision making
and discretion can override overpowering emotional arousal. Its as if every social cue is a
distress signal that could mean extinction in the eyes of a BPD patient: they are fighting for their
survival. To healthy individuals with healthy attachment styles, the BPD person might look
overactive and even immature. That is why it is so important to educate people, and especially
health care providers, on what is going on in the mind of those with BPD. With this
understanding one can employ compassion for the BPD patient. And compassion, empathy and
patience are very much needed in order to connect and make a healthy connection with the BPD
person, and due to the principals of neuroplasticity, change their minds in some little way.

References

References

Agrawal, H. R., Gunderson, J., Holmes, B. M., & Lyons-Ruth, K. (2004). Attachment studies
with borderline patients: A review. Harvard Review of Psychiatry, 12, 94104.
Ancona, A., Araujo, C. M., Araujo Filho, G. M., Araujo, T. B., Bressan, R. A., Carrete Jr., H.,
Jackowski, A. P., Lin, K., Lisondo, C. M., Sato, J. R., Silva, J. F. R. (2014) Cortical
morphology changes in women with borderline personality disorder: a multimodal
approach. Revista Brasileria de Psiquiatria, 36, 32-38.
Banich, M. T., Depue, B. E., Heller, W., Mackiewicz, K. L., Miller, G. A., & Whitmer, A. (2009).
Control mechanisms, emotion & memory: a neural perspec- tive with
implications for
psychopathology. Neurosci. Biobehav. Rev. 33, 613630.
Bandelow, B., Falkai, P., Schmahl, C., Wedekind, D. (2010). Borderline personality disorder:
a dysregulation of the endogenous opioid system. Psychological Review, 117(2) 623636.
Barker, L. A., Bowles, D. P., Drabble, J. (2014). Investigating the role of executive attentional
control to self-harm in a non-clinical cohort with borderline. Frontiers in Behavioral
Neuroscience, 8(274) 1-9.
Barone, L., Fossati, A., Guiducci, V. (2011). Attachment mental states and inferred pathways
of development in borderline personality disorder: a study using the Adult Attachment
Interview. Attachment & Human Development, 13(5) 451-469.
Bateman, A., & Fonagy, P. (2008). The development of borderline personality disorderA
mentalizing model. Journal of Personality Disorders, 22(1), 421.
Beeney, J. E., Levy, K. N., & Temes, C. M. (2011). Attachment and its vicissitudes in borderline
personality disorder. Current Psychiatry Re- ports, 13, 5059.
Beevers, C. G., Meyer, B., & Pilkonis, P. A. (2004). Whats in a (neutral) face? Personality
disorders, attachment styles, and the appraisal of ambiguous social cues. Journal of
Personality Disorders, 18, 320336.
Bhatia, V., Burckell, L., Davila, J., Eubanks-Carter, C. (2013). Appraisals of daily romantic
relationship experiences in individuals with borderline personality disorder
features. Journal of Family Psychology, 27(3) 518-524.
Bleiberg, E., & Sharp, C. (2007). Borderline personality disorder in children and adolescents. In
A. Martin & F. Volkmar (Eds.), Lewiss child and adolescent psychiatry: A
comprehensive textbook (4th ed., pp. 680691). Baltimore, MD: Lippincott Williams &
Wilkins.
Bohus, M., Elzinga, B. M., Krause-Utz, A., Niedtfeld, I., Oei, N. Y., Paret, C., Schmahl, C.,
Spinhoven, P. (2014). Amygdala and dorsal anterior cingulate connectivity during an

References
emotional working memory task in borderline personality disorder patients with interpersonal
trauma history. Frontiers in Human Neuroscience, 8(848) 1-18.
Bohus, M., Herpertz, S. C., Kirsch, P., Niedtfeld, I., Schmahl, C., Schulze, L. (2012). Functional
connectivity of pain-mediated affect regulation in borderline personality disorder. PLoS
ONE, 7(3) 1-9.
Carbone, C., Kim, S., Sharp, C. (2014). The protective role of attachment security for
adolescent borderline disorder features via enhanced positive emotion regulation
strategies. Personality Disorders: Theory, Research, and Treatment, 5(2) 125-136.
Cho, E., Essex, M. J., Kalin, N. H., & Klein, M. H. (2002). Maternal stress
beginning in infancy may sensitize children to later stress exposure: Effects on cortisol and
behavior. Biological Psychiatry, 52, 776784.
Chou, S.P., Goldstein, R.B., Grant, B.F., Huang, B., Saha, T.D., Stinson, F.S. (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. Journal of Clinical Psychiatry, 69(4), 533545.
Cho, D.Y., Han M.H., Lyoo, I.K. (1998) A brain MRI study in subjects with borderline
personality disorder. J Affect Disord. 50, 43-235.
Darke, S., Ross, J., Teesson, M., & Williamson, A. (2005). The impact of borderline personality
disorder on 12-month outcomes for the treatment of heroin dependence. Addiction, 100,
11211130.
Edvardsen, J., Kringlen, E., Lygren, S., ien, P. A., Onstad, S.,. Skre, I., Torgersen, S., (2000).
A twin study of personality disorders. Compre- hensive Psychiatry, 41, 416425.
Elst, L., Geiger, E., Haegele, K., Hesslinger, B., Lemieux, L., Tebartz van, Thiel, T. (2003)
Frontolimbic brain abnormalities in patients with borderline personality disorder: a
volumetric magnetic resonance imaging study. Biol Psychiatry. 54, 71-163.
Fan, J., Minzenberg, M.J., New, A.S., Siever, L.J., Tang, C.Y. (2007) Fronto-limbic dysfunction
in response to facial emotion in borderline personality disorder: an event-related fMRI
study. J Psychiatr Res.155, 231243.
Fonagy, P., Luyten, P., Strathearn, L. (2011). Borderline personality disorder, mentalization,
and the neurobiology of attachment. Infant Mental Health Journal, 321(1), 47-6
Grossmann, K., Grossmann, K. E., Kindler, H., & Zimmermann, P. (2008). A wider view of
attachment and exploration: The influence of mothers and fathers on the development of
psychological security from infancy to young adulthood. In J. Cassidy & P. R. Shaver
(Eds.), Handbook at attachment: Theory, research, and clinical applications (2nd ed., pp.
857879). New York, NY: Guilford Press.

References
Guzder, J., Paris, J., & Zweig-Frank, H., (1994). Risk factors for borderline personality in male
outpatients. Journal of Nervous and Mental Disease, 182, 375380.
Hatzitaskos, P., Kokkevi, A., Soldatos, C. R., & Stefanis, C. N. (1999). Substance abuse patterns
and their association with psychopathology and type of hostility in male patients with
borderline and antisocial personality disorder. Comprehensive Psychiatry, 40, 278282.
Jackson, A., Ludolph, P. S., Misle, B., Westen, D., Wiss, F. C., & Wixom, J. (1990). The
borderline diagnosis in adolescents: Symptoms and developmental history. American
Journal of Psychiatry, 147, 470476.