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Personality Disorders559emptiness. Above all, she is desperately afraid of abandonment and alternatelyclings to others and pushes them away. Because her sense of identity is so fragile,she constantly seeks reassurance and self-definition from others. When it is notforthcoming, she may erupt in furious anger or abject despair.Relationships careen out of control as the person shifts from inappropriately idealizingthe newfound lover or friend to viewing them with complete contempt orhostility. She sees herself, and everyone else, as absolutes: ecstatic or miserable, perfector worthless (South & others, 2008).The deep despair and inner emptiness that people with BPD experience are outwardlyexpressed in self-destructive behavior (Linehan & Dexter-Mazza, 2008).“Cutting” or other acts of self-mutilation, threats of suicide, and suicide attemptsare common, especially in response to perceived rejection or abandonment. Underscoringthe seriousness of borderline personality disorder is a grim statistic: As manyas 10 percent of those who meet the BPD criteria eventually commit suicide—a ratethat is 50 times that of the general population (American Psychiatric Association,2001; Crowell & others, 2009).Borderline personality disorder is often considered to be the most serious anddisabling of the personality disorders. People with this disorder often also sufferfrom depression, substance abuse, and eating disorders (Mercer & others, 2009;Walter & others, 2009). And because they often lack control over their impulses,self-destructive, impulsive behavior is common, such as gambling, recklessdriving, drug abuse, or sexual promiscuity.Along with being among the most severe of the personality disorders, borderlinepersonality disorder is also the most commonly diagnosed. A recent survey found thatBPD was more prevalent than previously thought. Estimates suggest that BPD affectsfrom 1.2 to 6 percent of the population, or possibly some 18 million Americans(Grant & others, 2008). The researchers also found the highest prevalence of borderlinepersonality disorder among women, people in lower income groups, and NativeAmerican men, while the lowest incidence was among women of Asian descent.What Causes Borderline Personality Disorder?As with the other personality disorders, multiple factors have been implicated. Becausepeople with borderline personality disorder have such intense and chronicfears of abandonment and are terrified of being alone, some researchers believe thata disruption in attachment relationships in early childhood is an important contributingcause (Fonagy & Bateman, 2008; Gunderson & Lyons-Ruth, 2008). Dysfunctionalfamily relationships are common: Many borderline patients report havingexperienced neglect or physical, sexual, or emotional abuse in childhood (Watson &others, 2006).A more comprehensive theory, called the biosocial developmental theory of borderlinepersonality disorder, has been proposed by psychologist Marsha Linehan (1993;Crowell & others, 2009). According to this view, borderline personality disorder isthe outcome of a unique combination of biological, psychological, and environmentalfactors. Some children are born with a biological temperament that is characterizedby extreme emotional sensitivity, a tendency to be impulsive, and the tendencyto experience negative emotions. Linehan believes that borderlinepersonality disorder results when such a biologically vulnerable child is raised bycaregivers who do not teach him how to control his impulses or help him learnhow to understand, regulate, and appropriately express his emotions (Crowell &others, 2009).In some cases, Linehan believes, parents or caregivers actually shape and reinforcethe child’s pattern of frequent, intense emotional displays by their own behavior.For example, they may sometimes ignore a child’s emotional outbursts andsometimes reinforce them. In Linehan’s theory, a history of abuse and neglect maybe present but is not a necessary ingredient in the toxic mix that produces borderlinepersonality disorder.