Borderline
personality disorder (BPD) is a misnomer. The term "borderline"
originated in the 1930s when psychiatrists thought that emotionally unstable
patients dwelt on the border between neurosis and psychosis. The
classification, Emotional Instability Disorder, better describes those
individuals who demonstrate the following:
Ø 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.
Ø Chaotic relationships
Ø Frantic efforts to avoid real or imagined
abandonment
Ø An unstable self-image
Ø Self damaging impulsivity such as
overspending, sexual indiscretion, substance abuse, reckless driving, binge
eating
Ø Recurrent suicidal behavior, gestures, or
threats
Ø Self-mutilating behavior—cutting or burning
self
Ø Rapid onset of intense and profound depression
Ø Rejection sensitivity—considered the slightest
inattention of an individual as a totally rejecting attitude
Ø Chronic feelings of emptiness
Ø Inappropriate, intense anger—screaming,
yelling, throwing things
Ø Transient paranoid thinking
Ø 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. Self-mutilation results from an attempt to
reduce emotional stress. For the borderline, physical pain is preferred over
emotional distress. People with BPD exhibit other impulsive behaviors, such as
excessive spending and risky sexual activity.
ORIGIN 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.
In
some cases over gratification and establishing an atmosphere that the child’s
uniqueness and special talents put him or her above all others contribute to
borderline dynamics. Sometimes poor parent-child bonding fails to develop.
As the years pass, feelings of
worthlessness, and a poor sense of self cause frequent changes in careers,
jobs, friendships, and values. Borderlines view themselves as fundamentally bad
or unworthy. They 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— A GENETIC
OR A PSYCHOSOCIAL ORIGIN?
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.
Common sense indicates that some
children are more sensitive than others. 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.
NEUROCHEMICAL MARKERS
The chemical messenger serotonin helps
regulate emotions, including sadness, anger, anxiety, and irritability. Drugs
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.
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.
BPD is one of four
related personality disorders associated with dramatic-erratic behavior, poor
impulse control, and emotional instability. Narcissistic, histrionic, and antisocial personality disorders are
also distinguished by dramatic-erratic behavior. While almost 75% of borderlines
are female, the vast majority of sociopaths (antisocial personality disorder)
are male.
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.
Seven elements of PSYCHODYNAMIC dialectic behavior
therapy:
- Corrective Emotional Response: A trustworthy
therapist who demonstrates non-possessive warmth (love without controlling
behavior) and genuine respect for the patient enables the patient to learn
self-soothing behavior that failed to develop due to childhood emotional
abandonment and poor parent-child interactions. Through verbal and
nonverbal behavior the therapist demonstrates emotional stability when the
patient exhibits angry outbursts, intense depressive episodes,
frustration, impulsivity, mutilation behavior, and excessive emotional
dependency. The therapist models and teaches self-discipline by setting
limits on emotional outbursts. The therapist avoids rescuing the patient from
conflicts of daily living while remaining kind and understanding.
- Psychodynamic Emotional Connections: By reviewing
childhood experiences the patient feels the connection between the childhood
emotional conflicts and present emotional distortions.
- Cognitive Behavior Therapy: The patient
practices changing thoughts to have better feelings.
- Improving Responses to Day-to-Day Events: The patient
keeps a daily journal that records events, 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.
- Developing Emotional Skills: Through a
series of questions the therapist explores the what, where, when, why, and
how of conflict and stress. The therapist teaches skills to deal with stress
and interpersonal conflict in the following areas:
v Evaluation of distorted thinking: The patient is helped to see different viewpoints in
a conflict.
v Dealing with stress: The patient learns to manage emotions that are triggered by distressing
events, including those that cannot be immediately resolved.
v Dealing with interpersonal conflict: The therapist teaches the patient to maintain healthy
relationships. The patient learns that certain rules of society must be followed
to get along in the world and to break social, ethical, and moral rules leads
to self-destruction. The therapist helps the patient find ways to fulfill emotional
needs while allowing others to fulfill their needs.
v 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 perceived rejection:
ü What are you thinking (or doing)
right now?
ü Is what you are thinking (or
doing) helping you?
ü What thoughts (or actions) can
help you feel better about yourself? (Several options may be formulated until
the best solution is discovered.)
ü Will you commit to changing your
thoughts (or actions)?
ü How will you demonstrate that you
have committed to change?
6. 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.
7. Medication Education: The risk and benefits of medications, how
medications work and medication side effects are explained to the patient.
