Borderline Personality Disorder
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Personality Disorders are psychiatric disorders which typically begin to develop in childhood and become deeply ingrained, pervasive, and inflexible ways of interacting with, coping in, and perceiving one’s environment by the time the person reaches adulthood. Unlike other disorders which may be episodic, such as depression or anxiety, Personality Disorders are ongoing, causing distress and / or significant problems for the individual.
Borderline personality disorder (BPD) was given its name due to an early theory that individuals with this disorder seemed to be on the “border line” of psychosis and neurosis. In fact, it was once believed to be an atypical type of schizophrenia. Even though current conceptualization of the disorder no longer reflects that, the name of the disorder has never changed despite pressure by some advocates to do so. An alternative name that has been considered, as it reflects one of the most salient aspects of the disorder, is “emotional regulation disorder”.
It is estimated that at least 2% of adults in the U.S. have borderline personality disorder. In outpatient settings, approximately one out of every ten individuals presents with BPD, and in psychiatric inpatient settings the number is nearly twice that. Although BPD is seen in both sexes, it is diagnosed nearly 3 times more often in females than in males.
Of all the personality disorders, BPD is one of the most challenging to treat. The clinical presentation is also one of the most taxing on treatment providers. Sadly, many individuals with BPD are in and out of treatment throughout their lives, often making only limited progress in terms of developing truly helpful coping skills.
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What does someone with BPD look like?
You may know someone with BPD. At first glance she may seem normal and nice. She may even be quite high functioning. However, as time goes on the issues begin to surface….
She is often moody - happy one minute and angry, sad, or irritable the next. You may find that you never know quite what to expect and feel you need to “walk on egg shells”. If you are in a relationship (such as a friend or significant other) with her, you may wonder why one minute she thinks you are the most wonderful person on the planet, and then just a short while later, she devalues you, shredding you with hurtful words as she finds nothing but fault. You may find yourself feeling that you’re “damned if you do and damned if you don’t”…. the term “no win situation” often seems to apply when dealing with someone who has BPD.
If you pull away, or attempt to end the relationship, she may beg and plead or go to drastic measures to get you to reconsider. She may even go so far as to threaten or attempt suicide or attempt harming herself in some dramatic manner. The emotional displays are excessive. At times she displays an intense anger that borders on rage.
Her decision-making is often based on impulse. Life goals may change frequently, as it seems she is always trying to figure out what she really wants in life. She often engages in reckless or high-risk activities, such as gambling, unprotected sex with several partners, or shopping like there’s no tomorrow. She may abuse alcohol, use drugs, or engage in binge eating as she tries to fill an internal emptiness or numb painful feelings.
She has a long list of people with whom she was once friends but is no longer. Her close relationships are often rocky and very intense. She longs to be loved yet inadvertently sabotages her relationships in a variety of ways. She tends to feel deeply flawed and worthless, and each failed relationship reinforces this self-perception.
As irritating and exasperating as she may be, it is important to realize that it is a “disorder”, and a very distressing one at that. Individuals with BPD often live chaotic lives. They seem to experience one crisis after another. These crises trigger intense emotions, and emotional control is very difficult for them.
Although the traits of a borderline are deeply ingrained, as is the nature of personality disorders, with appropriate treatment individuals with this disorder can significantly improve and have lives which are happy and fulfilling.
Criteria for a diagnosis of BPD
Symptoms of borderline personality often begin to appear in adolescence, but may not appear until early adulthood. They consistently appear in a many different contexts of the person’s life – i.e., they don’t appear only under certain circumstances. While there are nine clinical criteria for this disorder, an individual must meet at least five of them in order to qualify for a diagnosis of BPD. The nine indicators of BPD are as follows:
1. Desperate attempts to avoid actual or perceived abandonment (e.g., excessive begging and pleading, threats, extreme promises or bargaining). This does not include suicide attempts or self-mutilation (described in #5).
2. Relationship patterns which are intense and unstable; the individual goes back and forth between idealizing a person one moment and devaluing him or her the next. (Devaluing may be in reaction to an imagined slight or a misunderstanding. Borderlines tend to see everything in very black and white terms, lacking the ability to see shades of gray in situations. Hence, their reactions are often extreme.)
3. Distorted and unstable self-image – borderlines often perceive themselves as evil or bad, but at times may feel they don’t even exist. (Shifts in self-image often manifest in frequently changing goals, values, career plans, and / or types of friends.)
4. Impulsivity in at least two areas which are self-destructive, such as careless spending, reckless driving, gambling, unprotected sexual activity, substance abuse, or binge eating. (Self-mutilation and suicidal behavior are not included here – see #5.)
5. Recurrent suicide attempts, threats, or gestures, or any type of self-mutilation. (It is not uncommon for individuals with BPD to become suicidal, or cut or burn themselves in an attempt to alleviate distressing emotions. Rejection, separation, or the threat of abandonment is often a trigger.)
6. Difficulty managing intense emotions, and experiencing frequent mood swings (often irritable, anxious, angry, or depressed); the moods are intense and usually last for a brief period of time – i.e., a few hours to a few days at most.
7. A chronic sense of emptiness. (Individuals with BPD often get bored easily and, as a result, may constantly look for ways to alleviate the boredom.)
8. Intense, inappropriate feelings or displays of anger, and / or problems controlling their anger. (This may be shown by frequently flying into a rage, being angry or bitter all the time, or frequently getting into verbal or physical altercations. The anger is often triggered by feelings of neglect, withholding, or abandonment by someone important in their life.)
9. Fleeting paranoid ideation or dissociation during times of severe stress. (This generally occurs due to perceived or actual abandonment.)
Many symptoms of BPD are in reaction to the borderline’s intense fear of being alone. Even a short, time-limited period of separation from someone important can trigger an extreme reaction from a person with BPD.
Individuals with BPD are highly reactive to their environment. They are particularly sensitive to anything which taps into their deep-seated feelings of being worthless, unlovable, inherently bad or evil. If someone they care about begins to pull away, withholds affection, or seems uncaring or neglectful, borderline individuals may go into a rage, harshly devalue them, or become suicidal. These extreme and inappropriate reactions often take a toll on those they become closest to. The other person ends up feeling manipulated and often ultimately does abandon the relationship, further perpetuating the borderline’s feelings of worthlessness. Unfortunately, these reactions are deeply ingrained for the borderline individual, making change very difficult. While BPD is at times diagnosed in adolescence, it is usually diagnosed in adulthood. During the teen years it is not uncommon to display symptoms which mimic BPD, such as moodiness, emotional outbursts, and identity issues. These typically disappear as the person matures if they do not have BPD.
What causes BPD?
There is no known specific cause of BPD. Rather, it is believed that a combination of three factors - genetics, biology, and one’s environment during the developmental years – likely cause its development. While research has been done to explore the etiology of BPD, much more research is needed to provide a definitive answer.
Genetic and biological factors in the development of BPD
Early research suggested that BPD ran in families. However, it was unknown as to whether or not that was due to genes or the family environment. More recent research, including twin studies, suggests that genetics likely predisposes a person to this disorder. Individuals who have an immediate family member with BPD are approximately 5 times more likely to have the disorder than those in the general population. Research suggests that individuals with BPD may have a gene that affects serotonin. Serotonin is a neurotransmitter that plays a key role in mood regulation. It is associated with depression and anxiety. Serotonin has also been believed to play a potential role in the development of schizophrenia. Individuals with BPD may also have structural and functional differences in their brain compared to people who do not have BPD. Their emotional instability may be a result of unusually high activity in the region of the brain associated with emotional regulation and expression.
Environmental factors in the development of BPD
Many individuals with BPD come from a stressful or chaotic childhood environment which included sexual or physical abuse, neglect, abandonment by or separation from primary caregivers, emotional trauma, or parents who invalidated them. However, not all borderlines had a difficult childhood, and not everyone from such a background develops BPD.
Treatment for BPD
It was once believed that individuals with BPD would never get better. Sadly, many do not benefit from treatment. In fact, hospitalization is often contra-indicated for individuals with BPD, as they often regress during hospital stays. However, it may be necessary to keep them safe if they are at imminent risk for suicide or self-harm.
Psychotherapy
Therapists who have borderlines as clients often find it frustrating as they don’t always show up for sessions and can be extremely demanding or manipulative. It can be emotionally draining to treat them, and since they frequently engage in suicidal or self-mutilating behavior, they are particularly high risk clients.
Dialectical Behavior Therapy
In recent years, therapy specific to the treatment of BPD has been shown to be quite effective. Dialectical behavior therapy (DBT), developed by Dr. Marsha Linehan in the late 1970s, is currently one of the most widely used treatments for BPD. DBT focuses on helping individuals with borderline personality disorder learn good coping skills, manage intense emotions and stress, and interact more successfully in their relationships with others.
DBT includes regular individual therapy sessions, phone sessions, and weekly group sessions for the patients. It also provides support for the therapists involved in the treatment process via weekly team meetings. This latter component also helps make the treatment more successful for the patients.
Transference-focused Psychotherapy (TFP)
Transference-focused psychotherapy is another type of therapy also developed specifically for the treatment of BPD. It utilizes the therapist – client relationship as part of the therapy process. “Transference” refers to the way in which therapy clients will often project or “transfer” their feelings about significant people in their lives onto the therapist. The therapist, in turn, can use this dynamic to help clients learn healthier ways of interacting with other people in their life.
Medication
While medication by itself is ineffective for treating BPD, it can be beneficial as an adjunct treatment. Symptoms of depression, anxiety, anger, paranoid thoughts, and impulsivity may benefit from medication. The medications prescribed for borderlines may include antidepressants, mood stabilizers, and antipsychotics.
Hospitalization
Brief hospitalization is necessary at times for individuals with BPD. Due to their high risk of suicide gestures and attempts, as well as self-mutilation, they may need to be hospitalized in order to help keep them safe. While a brief hospitalization can increase safety and provide a temporary break from outside stressors, lengthy hospital stays are generally not the best treatment for borderline individuals as they tend to regress during extended inpatient stays.
Complications of BPD
Individuals with BPD often have significant difficulties at work, in relationships, at school, and with self-esteem. It is not uncommon for them to lose jobs or end up divorced as a direct result of their disorder. Individuals with this disorder are also at risk of ending up in abusive relationships, as victim or abuser. Due to their impulsive and self-destructive tendencies, they are also at high risk for car accidents, STDs, unplanned pregnancies, fights, and drug and alcohol problems.
Successful suicides occur among individuals with BPD at alarming rates, ranging from 10 to 15 percent. Multiple hospitalizations are not uncommon for their suicidal behavior and self-mutilation. Self-mutilation also leaves them with life-long scars on their bodies, which can be difficult to hide or explain to others. If you suspect that you or a loved one may be suffering from borderline personality disorder, there is hope. Contact a qualified mental health professional for an evaluation. Diagnosis is the first step, followed by a good treatment plan. Treatment for BPD is not brief, but the right kind of treatment can potentially make a significant difference in the long run.
