Risk factors for BPDNational Health and Medical Research Council. Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne: National Health and Medical Research Council The systematic review included prospective population cohort studies, prospective cohort studies with matched control groups, and retrospective cohort studies with matched control groups.
The included studies identified a number of early childhood variables that were associated with increased probability of developing BPD, including socioeconomic deprivation, trauma or stressful life events, poor or inconsistent parenting, and co-occurring psychiatric conditions.
In addition to the evidence identified by the systematic review, the Committee also considered a recent narrative review of studies that have evaluated biological and environmental factors as potential risk factors for BPD (including prospective studies of children and adolescents, and studies of young people with BPD). Evidence from these studies is summarised as follows.
3.1.2.1
Genetic risk factors Individuals with a ‘sensitive’ genotype appear to be at greater risk of developing BPD when exposed to environments that predispose people to BPD. Genes that influence BPD features may also increase the risk of co-occurring illness and the risk of some adverse life events.
3.1.2.2
Environmental risk factors A range of childhood and parental demographic characteristics, adverse childhood experiences (including neglect, trauma and abuse), early interpersonal difficulties, and forms of maladaptive parenting have been identified as risk factors for adolescent and adult BPD.
A large prospective cohort study (the Children in the Community study) in the United States of America (USA) reported that childhood physical abuse, sexual abuse or neglect, maladaptive parenting, maladaptive school experiences, and demographic characteristics (including low family socioeconomic status, family welfare support recipient status, single-parent family status) were risk factors for adolescent and adult personality disorders including BPD.
Another prospective study in the USA (the Minnesota Longitudinal Study of Risk and Adaptation), which followed a cohort of low-income mothers and their babies from infancy to adulthood, reported that the number of BPD symptoms in offspring at age 28 years significantly correlated with early attachment disorganisation and maltreatment, maternal hostility and boundary dissolution, family disruption related to the father’s presence, and family life stress. Maternal hostility and life stress contributed independently to the prediction of offspring BPD symptoms at age 28 years.
The high prevalence of disturbed attachment among adults with BPD suggests that disruption of the process of attachment between the infant/child and primary caregivers in early life may be a marker of vulnerability to BPD. However, few prospective, longitudinal studies have investigated the effect of attachment organisation on the development of BPD to establish whether it is a risk factor.
Neurobiology and experimental psychopathology research Neurobiological research in adults suggests that abnormalities in frontolimbic networks are associated with many of the features of BPD. However, it is unclear whether these abnormalities are a cause of BPD, an effect of BPD, or are related in some other way.
Findings from the field of experimental psychopathology have not provided clear and consistent findings that explain developmental pathways to BPD.
3.1.2.4
Precursors for BPD Longitudinal data suggest that most adults with mental illnesses have similar mental state abnormalities (precursors)i that can be traced back to childhood and adolescence. Evidence is emerging that BPD features such as impulsivity, negative affectivity and interpersonal aggression might become established in childhood. A number of precursor signs and symptoms during adolescence have been associated with subsequent onset of BPD:
- Substance use disorders during adolescence, particularly alcohol use disorders, specifically predict young adult BPD.
- Disruptive behaviour disorders (including conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder) in childhood or adolescence predict personality disorders, including BPD, in young adulthood.
- Depression in childhood or adolescence predicts personality disorders, including BPD, in young adulthood.
- Repetitive deliberate self-harm in children may be a predictor of BPD.
3.1.2.5
Non-specific factors Evidence from some prospective and retrospective studies suggests that adverse experiences causing biological or psychosocial stress during the first few years of life increase a child’s risk of a range of mental health problems and mental illnesses.
Preventing BPD The Children in the Community study observed that a reduction in cluster B (including borderline) personality disorder symptoms was independently associated with attendance at schools characterised as ‘high in learning focus’ (i.e. teachers usually return marked homework and most students are interested in achieving high marks).
The Committee determined that there was insufficient evidence to formulate evidence based recommendations on the prevention of BPD. The Committee agreed on the following considerations:
- Adolescents and young people with emerging substance use disorders, disruptive behavior disorders, depression or self-harm should receive prompt psychosocial support and treatment as appropriate, because these may be precursors of BPD or another personality disorder.
- Given the association between disruption of the process of attachment between infant/child and primary caregivers in early life, and later development of BPD, it is possible that the risk of BPD might be reduced by interventions that improve the chance of organised attachment in infants at risk of attachment difficulties, such as those whose mothers have BPD.
- Given the evidence that adverse experiences during the first 3–4 years of life increase a child’s risk of a range of mental health problems and mental illnesses, interventions targeting families at risk might help reduce BPD rates as well as rates of other conditions.
Recommendations for population-level interventions to reduce rates of child abuse and neglect (such as social policy to reduce socioeconomic deprivation, or general parenting skills programs to support at-risk families) are outside the scope of this guideline.
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