Borderline Personality Disorder

Overview

Borderline Personality Disorder (301.83) “is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.” (pg. 706. Supplementary to this definition Dr. Larry J. Siever in Stop Walking on Eggshells (1998) writes, “…BPD represents a series of maladaptive traits that stem from survival strategies developed early on in the life of the BP that, at the time, seemed the only viable method to get their needs met.” (pg. viii)[/ref] It has an estimated prevalence rate of 2%[1] in the general population, but is one of the most common personality disorders “among clinical populations.” (pg. 708)

BPD seems to be one of the personality disorders with the best hopes of remission. The DSM-IV-TR notes, “Follow-up studies of individuals identified through out-patient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of behavior that meets full criteria…” (pg. 709)

They Named It What?

I’ve always been confused by the name “Borderline Personality Disorder” – b/c I’ve never understood how it exemplified the symptoms it described. Recently I read that BPD was named at a time when it was thought that individuals demonstrating these symptoms where on the “borderline” between psychosis and neurosis. I hope someday they’ll choose to rename the disorder to something more appropriate. I think I’ve seen “Emotionally Unstable Disorder” mentioned a few times, though is only partially satisfactory as a descriptor and there are probably better descriptors available.

Causes

As with many disorders, BPD appears to have a “strong biological component…”[2] Thus it is unlikely or perhaps even impossible for someone without the biological predisposition to BPD to “get” BPD. On the other hand, it seems clear that BPD is not solely the result of biology – one can be predisposed to BPD biologically but never get BPD. According to the AAMFT childhood trauma seems to be a common thread in a majority of BPD cases[3] – this may be the trigger which causes biologically predisposed individuals to manifest the disorder. This would include sexual, verbal, or physical abuse as well as abandonment or neglect by primary caregivers.

Diagnostic Criteria

“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five…of the following:

  1. frantic efforts to avoid real or imagined abandonment…
  2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  3. identity disturbance: markedly and persistently unstable self-image or sense of self
  4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)…
  5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  6. affective irritabilitydue to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
  7. chronic feelings of emptiness
  8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  9. transient, stress-related paranoid ideation or severe dissociative symptoms” (pg. 710)

Distinguishing from Other Disorders

There is overlap between the personality disorders, but each disorder has some distinguishing features which are not present in the other disorder (though it is possible that an individual may have the distinguishing feature of both, in which case they are likely to be diagnosed as having both personality disorders).

Personality Disorder Distinguishing Features from Borderline Personality Disorder
Histrionic Is not: self-destructive, anger-driven disruptions in relationships, continual feelings of emptiness (loneliness). (pg. 709)
Schizotypal Is: sustained in its paranoid ideas, do not depend on interpersonal relationships and/or external circumstances. (pg. 709)
Paranoid Is not: self-destructive, impulsive, or fearing abandonment. (pg. 709)
Narcissistic Is not: same as for paranoid.
Antisocial Manipulates in order to “gain profit, power, or some other material gratification” while BPD “is directed more toward gaining the concern of caretakers.” (pg. 710)
Dependent Reacts to real/imagined abandonment by “increasing appeasement and submissiveness” whereas BPD “reacts…with feelings of emotional emptiness, rage, and demands…” (pg. 710)

Treatment

Medication

According to the AAMFT (MacFarlane), neurotransmitters appear to be heavily involved in the mood instability found in BPD. Lieb, et al. indicates that while there is no panacea for the medicinal treatment of BPD, some medications may assist in reducing specific symptoms – e.g. anti-depressants and mood stabilizers. Lieb also noted that Omega-3 supplements seemed to have a positive effect on individuals struggling with BPD.

Counseling

The AAMFT (MacFarlane) mentions psychodynamic, Cognitive Behavioral Therapy (CBT), and Dialectical Behavior Therapy (DBT) as primary modalities of counseling in the treatment of BPD. DBT is a sub-type of CBT and appears to be the most effective. The Mayo Clinic notes DBT as being especially designed to treat BPD. It also suggests that Mentalization-Based Therapy (MBT), Schema-Focused Therapy (SFT), and Transference-Focused Psychotherapy (TFP) (Treatment and Drugs).

Examples

  • Randi Kreger writes concerning her interactions with a BPD individual, “Why did he act so loving one moment and then rip me to shreds the next? Why did he tell me I was talented and wonderful and then scream at me that I was contemptible and the cause of all his problems? If he loved me as much as he said he did, why did I feel so manipulated and powerless? And how could someone so intelligent and educated sometimes act so completely irration?” (Mason, 1)
  • The Mayo Clinic Staff writes, “With borderline personality disorder, you may have a severely distorted self-image and feel worthless and fundamentally flawed. Anger, impulsiveness and frequent mood swings may push others away, even though you may desire to have loving and lasting relationships.” (Definition)
  • “When you have borderline personality disorder, you often have an insecure sense of who you are. Your self-image, self-identity or sense of self often rapidly changes. You may view yourself as evil or bad, and sometimes you may feel as if you don’t exist at all. An unstable self-image often leads to frequent changes in jobs, friendships, goals and values.” (Mayo, Symptoms)
  • “Your relationships are usually in turmoil. You may idealize someone one moment and then abruptly and dramatically shift to fury and hate over perceived slights or even minor misunderstandings. This is because people with borderline personality disorder often have difficulty accepting gray areas — things seem to be either black or white.” (Mayo, Symptoms)

Other Notes

  • The suicide rate amongst BPD’s is extremely high – perhaps fifty times that of the entire population.
  • Individuals with BPD oftentimes have other disorders as well – namely depression, substance abuse, PTSD, anxiety disorders, and eating disorders.

Recommended Reading

  • Klaus Lieb, Mary C Zanarini, Christian Schmahl, Marsha M Linehan, Martin Bohus. “Borderline Personality Disorder.” Lancet, 2004: 364: 453-61. – This article, while a little dated, provides a good overview of many aspects of BPD beyond what one might find in most articles dealing with BPD.

Recommended Websites

  • BPDCentral – Founded by Randi Kreger, well-known for her book Stop Walking on Eggshells about Borderline Personality Disorder.

Recommended Blogs

Bibliography

  1. [1]Kreger estimates six million in North America suffer from BPD.
  2. [2]MacFarlane
  3. [3]MacFarlane

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