Definition
Borderline personality: Persons with this personality disorder--predominantly women--are unstable in their self-image, mood, behavior, and interpersonal relationships. This personality disorder becomes evident in early adult years, but it tends to become milder or to stabilize with age. Such persons believe they were deprived of adequate care during their childhood and consequently feel empty, angry, and entitled to nurturance. As a result, they are relentless seekers of care. This personality disorder is by far the most common type seen in psychiatric and all other types of health care services.

When persons with a borderline personality feel cared for, they appear like lonely waifs, who seek help for depression, substance abuse, eating disorders, and past mistreatments. However, when they fear the loss of the caring person, their mood shifts dramatically and is frequently expressed as inappropriate and intense anger. The shift in mood is accompanied by extreme changes in their view of the world, themselves, and others--from black to white, from hated to loved, or vice versa (see splitting in Table 191-1). Their view is never neutral. When they feel abandoned (ie, all alone), they dissociate or become desperately impulsive. At times, their concept of reality is so poor that they have brief episodes of psychotic thinking, such as paranoid ideas and hallucinations.

Such persons have far more dramatic and intense interpersonal relationships than those with cluster A personality disorders. Their thought processes are disturbed more than those of persons with an antisocial personality, and aggression is more often turned against the self. They are more angry, more impulsive, and more confused about identity than those with a histrionic personality. They tend to evoke intense, initially nurturant responses in caretakers. But after repeated crises, vague unfounded complaints, and failures to comply with therapeutic recommendations, caretakers--including the physician--often become very frustrated with them and view them as help-rejecting complainers. Splitting, acting out, hypochondriasis, and projection are common
coping mechanisms (see Table 191-1).

Antisocial personality (previously called psychopathic or sociopathic): Persons with this personality disorder callously disregard the rights and feelings of others. They exploit others for materialistic gain or personal gratification (unlike narcissistic persons, who exploit others because they think their superiority justifies it). Characteristically, they act out their conflicts in impulsive and irresponsible ways, sometimes with hostility and serious violence. They tolerate frustration poorly.
Often they do not anticipate the negative consequences of their antisocial behaviors and typically do not feel remorse or guilt afterward. Many of them have a well-developed capacity for glibly rationalizing their behavior or for blaming it on others. Dishonesty and deceit permeate their relationships. Punishment rarely modifies their behavior or improves their judgment and foresight; it usually confirms their harshly unsentimental view of the world.Antisocial personality disorder is often associated with alcoholism, drug addiction, infidelity,
promiscuity, failure in one's occupation, frequent relocation, and imprisonment. In Western culture, more men have this personality disorder than women, and more women have a borderline personality; these two disorders have much in common. In the families of patients with both personality patterns, the prevalence of antisocial relatives, substance abuse, divorces, and childhood abuse is high. Often, the patient's parents have a poor relationship, and the patient was severely emotionally deprived in his formative years. Life expectancy is decreased, but among survivors, the disorder tends to diminish or stabilize with age.