All too often, mainstream psychiatry focuses almost solely on medication management, ignoring the evaluation and treatment of physiological factors that underlie and contribute to mental illness. Borderline personality disorder is a condition that sets a stark example of the failures of this approach.
Borderline personality disorder (BPD) is a chronic mental illness that markedly interferes with a person’s capacity to control or regulate their emotions. Due to these challenges with emotional regulation and control, individuals with BPD have increased impulsivity, poor self-esteem and unstable social interactions and relationships. And while treatment of BPD is often attempted through the use of multiple medications, the research does not generally support their use in reducing BPD symptoms (Gartlehner 2021).
In my own experience, a functional medicine approach dramatically improves the treatment of BPD, especially when combined with appropriate psychotherapy. Like other mental health conditions, individuals struggling with BPD often have nutritional deficits, hormonal dysregulation, toxicities, genetic polymorphisms, chronic inflammation and infections that all can be contributing to their current expression of symptoms. When you optimize brain function by addressing these underlying components first, psychotherapeutic interventions can be significantly more effective.
Two of the keys that shouldn’t be overlooked for treating borderline personality disorder involve essential fatty acids and cholesterol.
Omega-3 Fatty Acids for Borderline Personality Disorder
The brain is made up of a large percentage of fat, including essential fatty acids. To maintain brain health, a steady supply of essential fatty acids is needed to support normal function.
Research has shown that essential fatty acids are crucial for healthy cell membrane activity, playing a role in the regulation of numerous neurotransmitters, including dopamine, serotonin and norepinephrine (Liu 2016). Without adequate omega-3 fatty acids, neurotransmitter function can become severely dysregulated.
Chronic inflammation is a process that can cause significant damage and dysfunction in the brain. Elevated inflammation is also known to be a common component correlated with mental illness. Targeting and reducing brain inflammation is another component of the potential benefits from supplementing omega-3 essential fatty acids (Layé 2018).
These effects on neurotransmission and inflammation are likely directly relevant in the treatment of BPD. In fact, clinical trials investigating the effects of supplementing omega-3 fatty acids on BPD have found benefits. A recent meta-analysis concluded that fish oil significantly reduces both impulsivity and irritability in BPD patients (Karaszewska 2021). Considering that no prescription medications have been shown to consistently improve core BPD symptoms, these results are impressive.
In my own clinical experience with thousands of patients, omega-3 fats, typically from fish oil, have been incredibly useful for treating BPD. They typically form part of a solid foundation of a more comprehensive treatment strategy.
Does Cholesterol Affect BPD?
While often vilified, cholesterol is an essential component of cell membranes and the precursor to the steroid hormones. Without cholesterol, cells cannot function. The brain, which only makes up around 2% of body weight, contains around 25% of the body’s total cholesterol (Björkhem 2004). Also worth noting, data has repeatedly found that low cholesterol levels are strongly associated with the risk of suicide. A meta-analysis that included over half a million subjects found that low total cholesterol approximately doubled the risk (Wu 2016).
BPD patients are at much higher risk for suicide than the standard population. In fact, research suggests that BPD patients have a staggering 50 times higher risk (Pompili 2005). In addition, patients with BPD often have low levels of cholesterol, making the assessment and treatment of low cholesterol a critical component of suicide prevention. While not all of the data is consistent, a small study on BPD with self-harming tendencies found that decreasing total and LDL cholesterol levels correlated with increasing self-mutilation behaviors (Korkmaz 2016). A separate small study found that lower cholesterol levels in BPD correlated with all aspects of the condition, including impulsivity, aggression and suicidality (Atmaca 2002).
Addressing low cholesterol once it has been identified is simple: increase the oral intake of healthy foods high in cholesterol. Eggs, shrimp and liver are all good food sources. Supplemental cholesterol is also available if needed.
Preventing suicide in BPD patients is a critical component of treatment. Checking cholesterol levels should be part of a comprehensive initial assessment to help identify patients who may be at higher risk.
Want to learn how to address nutritional and hormonal imbalances in your patients with BPD? Check our our popular Fellowship program and book a private phone call with Dr. James Greenblatt to learn more!
Atmaca M, Kuloglu M, Tezcan E, Gecici O, Ustundag B. Serum cholesterol and leptin levels in patients with borderline personality disorder. Neuropsychobiology. 2002;45(4):167-171. doi:10.1159/000063665
Björkhem I, Meaney S. Brain cholesterol: long secret life behind a barrier. Arterioscler Thromb Vasc Biol. 2004;24(5):806-815. doi:10.1161/01.ATV.0000120374.59826.1b
Gartlehner G, Crotty K, Kennedy S, et al. Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis. CNS Drugs. 2021;35(10):1053-1067. doi:10.1007/s40263-021-00855-4
Karaszewska DM, Ingenhoven T, Mocking RJT. Marine Omega-3 Fatty Acid Supplementation for Borderline Personality Disorder: A Meta-Analysis. J Clin Psychiatry. 2021;82(3):20r13613. Published 2021 May 4. doi:10.4088/JCP.20r13613
Korkmaz S, Üstündağ B, Özer Ö, et al. Copeptin levels and blood lipid profile in borderline patients with or without self-mutilation. S Afr J Psychiatr. 2016;22(1):976. Published 2016 Oct 24. doi:10.4102/sajpsychiatry.v22i1.976
Layé S, Nadjar A, Joffre C, Bazinet RP. Anti-Inflammatory Effects of Omega-3 Fatty Acids in the Brain: Physiological Mechanisms and Relevance to Pharmacology. Pharmacol Rev. 2018;70(1):12-38. doi:10.1124/pr.117.014092
Liu JJ, Green P, John Mann J, Rapoport SI, Sublette ME. Pathways of polyunsaturated fatty acid utilization: implications for brain function in neuropsychiatric health and disease. Brain Res. 2015;1597:220-246. doi:10.1016/j.brainres.2014.11.059
Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: a meta-analysis. Nord J Psychiatry. 2005;59(5):319-324. doi:10.1080/08039480500320025
Wu S, Ding Y, Wu F, Xie G, Hou J, Mao P. Serum lipid levels and suicidality: a meta-analysis of 65 epidemiological studies. J Psychiatry Neurosci. 2016;41(1):56-69. doi:10.1503/jpn.150079