Borderline personality disorder is a common diagnosis among young women adapting to their new roles as mothers. Mindpath Health’s Elisabeth Netherton, MD, explains how this can affect children, families, and communities at large in this Psychiatric Times article.
Women adapting to their new roles as mothers can struggle with substantial mental health challenges. Postpartum depression, 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. Borderline personality disorder (BPD) is a common diagnosis among young women that is highly understudied in pregnancy and motherhood.
The 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. BPD is overwhelmingly diagnosed in women; around 87% of those receiving diagnoses are female. It is also thought to be associated with a higher degree of disability in women. The 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.
BPD is linked to challenges in pregnancy. 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 nicotine or other addictive substances during pregnancy. Women with BPD have shown overall low rates of adherence to prenatal care and an overall high likelihood of experiencing pregnancy as traumatic.
Sense of self
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.
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 comorbid substance use disorder. The negative impacts of substance use in pregnancy have been well documented.
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.
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 a 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 lead to improvement in these areas.
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.
Read the full Psychiatric Times article with sources.