- Ambivalent feelings about others—an “I hate you, don’t leave me” attitude. The borderline has intense love-hate relationships—thinking that a person is angel or a devil with no realization that all of us have “good” and “bad” traits. A few minutes or hours later, the borderline might idealize an individual and the next hour (or minute) the borderline will consider the individual worthless or evil.
- Chaotic relationships
- Frantic efforts to avoid real or imagined abandonment
- An unstable self-image
- Self damaging impulsivity such as overspending, sexual indiscretion, substance abuse, reckless driving, binge eating
- Recurrent suicidal behavior, gestures, or threats
- Self-mutilating behavior—cutting or burning self
- Rapid onset of intense and profound depression
- Rejection sensitivity—considered the slightest inattention of an individual as a totally rejecting attitude
- Chronic feelings of emptiness
- Inappropriate, intense anger—screaming, yelling, throwing things
- Transient paranoid thinking, self-image, and behavior.
- Emotional instability that disrupts family and work life
People with BPD often have highly unstable patterns of social
relationships. While they can develop intense but stormy attachments, their
attitudes towards family, friends, and loved ones may suddenly shift from
idealization (great admiration and love) to devaluation (intense anger and
dislike). They may form an immediate attachment and idealize the other person,
but when a slight separation or conflict occurs, they switch unexpectedly to
the other extreme and angrily accuse the other person of not caring for them at
all.
Individuals with BPD are highly sensitive to rejection, reacting with
anger and distress to such mild separations as a vacation, a business trip, or
a sudden change in plans. Suicide threats and attempts occur as a maladaptive
attempt to prevent abandonment. Intense anger develops when the borderline
feels rejected. People with BPD exhibit impulsive behaviors, such as excessive spending and risky sexual activity.
For the borderline, physical pain is preferred over emotional distress. Self-mutilation results from an attempt to reduce emotional
stress.
A QUINTET
CAUSATIVE THEORY OF BORDERLINE PERSONALITY
- A genetic predisposition to emotional instability and impulsive aggression
- Intense emotional activity as reflected in enhanced amygdala, cingulate gyrus and prefrontal activation in PET scanning and fMRI studies
- A traumatic childhood---abandonment, sexual or physical abuse
- Inattention to the child’s emotions and attitudes
- Exaggerated paternal frustration that aggravates the child’s anger and fears
PSYCHODYNAMICS OF
BORDERLINE BEHAVIOR
Anyone who has a child knows that around 18-months of age the youngster
toddles out of the room plays alone for a few minutes and then toddles back in
the room looking for mother. With a wide-eyed smile, mama picks up her toddler,
gives a warm hug, and coos encouragement. Consistent maternal and paternal
affection enables the child to develop a stable sense of self and, with
dependable parental behavior, the child develops the ability to sooth the
self—the ability to tolerate the vicissitudes of life.
When the-soon-to-become borderline toddles back into
the room, mama has disappeared or is drunk or is verbally, emotionally,
physically, or sexually abusive. Inconsistent, negligent, and abusive parental
behavior generates a fear of abandonment and retards the toddler’s emotional
development. The toddler feels alone, lost, and worthless.
As the years pass, feelings of worthlessness, and a
poor sense of self cause frequent changes in careers, jobs, friendships, and
values.
Borderlines feel
unfairly misunderstood or mistreated, bored, and empty. These feelings result
in frantic efforts to avoid being alone. The emotional clinging behavior
exhibited by borderlines repulses others. The fear of abandonment felt by the
borderline generates hostile behavior that results in the very rejection that
the borderline fears.
NATURE VERSUS
NURTURE: GENETIC OR PSYCHOSOCIAL ORIGIN?
Just as some geneticists believe they have isolated a
gene for shyness, a gene that serves as a biological marker for BPD may be
identified. Remember—a gene must be activated before an illness occurs. That
is, many of us may have a genetic marker for schizophrenia, but a stable
emotional life prevents the gene from becoming activated.
BIOLOGICAL
MARKERS
Although no gene has been identified as a precursor
to borderline personality disorder, neuroimaging studies are intriguing. PET
scanning and fMRI studies demonstrate enhanced amygdala and prefrontal
activation in subjects with BPD. Excess activity in the cingulate gyrus is
associated with borderline personality disorder. These findings are nonspecific
indicators of intense emotional activity.
Illnesses ASSOCIATED WITH BORDERLINE PERSONALITY DISORDER
BPD often occurs together with other psychiatric
problems, particularly bipolar disorder and depression. While a person with
depression or bipolar disorder typically endures the same mood for weeks, a
person with BPD may experience intense bouts of anger and depression that may
last only hours, or at most a day.
Bulimia and other eating disorders,
dissociate states, and anxiety syndromes are commonly associated with BPD.
Substance abuse is a
common problem in BPD. 50% to 70% of psychiatric inpatients with BPD are drug
or alcohol dependent.
MEDICATIONS TO
IMPROVE EMOTIONAL SYMPTOMS
- The chemical messenger serotonin helps regulate emotions, including sadness, anger, anxiety, and irritability. SSRIs such as Zoloft, Celexa, Lexapro that enhance brain serotonin function may improve emotional symptoms in BPD.
- Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings.
- An imbalance of dopamine, the so-called pleasure neurotransmitter, may contribute to impulsivity and anger. Antipsychotic medications can help regulate dopamine balance.
FAMILY/MARITAL THERAPY
The crux of family therapy involves educating family members regarding BPD. Improving communication will help resolve the two poles of inappropriate family response: over involvement (rescuing) and neglect.
SEVEN elements of dialectic behavior
therapy
- The therapist communicates verbally and nonverbally to the patient that the therapist cares enough to be involved in helping the patient learn self-disciple. The therapist sets limits. He/she does not give into the excessive demands of the patient. At the same time, the therapist is reliable and steady. The therapist avoids rescuing the patient when the patient gets into difficulties in his/her daily activities of living while remaining kind and understanding.
- The patient keeps a daily journal that records events and feelings and thoughts generated by daily events. The therapist asks a series of questions to enable the patient to learn better ways of handling conflict.
- Dialectic behavior therapy is based on the Socratic method of discovering the truth. The therapist helps the patient explore the what, where, when, why, and how of conflict and stress.
- Evaluation of distorted thinking—the patient is helped to see different viewpoints in a conflict and to focus on present issues instead feelings from the past.
- Dealing with stress—the patient learns to manage emotions that are triggered by distressing events, including those that cannot be immediately resolved.
- Dealing with conflict with others—the patient is assisted in maintaining good relationships with others. Through a series of questions the therapist helps the patient learn that certain rules of society must be followed to get along in the world, and that to break social, ethical, and moral rules leads to self-destruction. Using the Socratic method the therapist helps the patient find ways to fulfill his or her needs in a way that allows others to fulfill their needs.
- Developing emotional stability—the patient learns self-soothing behavior by changing distorted beliefs and inappropriate actions. For example, a series of questions can help improve the patient’s response to stress:
- What are you thinking (or doing) right now?
- Is what you are thinking (or doing) helping you?
- What thoughts (or actions) can help you feel better about yourself? (Several options may be formulated until the best solution is discovered.)
- Will you commit to changing your thoughts (or actions)?
- How will you demonstrate that you have committed to change?
PROGNOSIS
A combination of appropriate medications and dialectic behavior therapy vastly improves the prognosis for those suffering from borderline personality disorder.
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