Borderline Personality

Borderline Personality Disorder (BPD) is a serious mental health condition characterized by 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. ” (DSM-IV). BPD individuals are often preoccupied with fears and threats of abandonment that can lead to problems in their interactions with family and friends and in their intimate relationships.

Their personal life might also be impaired due to their intense bursts of anger and emotional displays that may also impair their job situation or cause them to frequently lose their job. Their education might be interrupted and they are frequently involved in broken marriages. They generally make frantic efforts to avoid abandonment, whether real or imagined and have an increased risk for major depression, substance dependence or abuse and posttraumatic stress disorder. The problems that arise reinforce their fears and create a self-fulfilling prophecy.

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Their fear of intimacy and its tendency to lead to unstable intimate relationships can lead to their personality merging with the identity of others or to being subjugated to other personalities. Such individuals may alternate between the desire for closeness and the need for distance. They are also given to a sudden shift in identity and to rapid changes in value. Such individuals may suddenly change their goals or their career goals in a rather impulsive manner. They can develop into transient reactive psychoses and may be chronically depressed.

It is not uncommon to encounter BPD individuals with most other personality disorders as BPD symptoms and characteristics often co-exist with most other personality disorders such as schizotypal behavior, histrionics, narcissistic behavior and antisocial behavior or antisocial personality disorder. As a result, the general picture we have of a BPD individual is a person with a serious mental illness marked by low self-image and by unstable moods and interpersonal relationships. BPD patients generally need extensive mental health services.

With help, their situation may improve over time and allow them to lead productive lives. Similar to schizophrenic individuals, borderline individuals may have difficulty distinguishing fact from fiction, reality from fantasy. Thus, for example, they can exaggerate minor medical situations by turning them into major, life-threatening events. Their exaggeration and fears can lead them to delay seeking medical assistance and treatment for health problems because they fear the worst possible diagnosis.

They may mistrust physicians, perhaps because of fear or of past experiences with health care providers. A subconscious need or desire to suffer in order to atone for feelings of guilt is common in borderline individuals. BPD individuals generally have a distorted appraisal of their medical situations, of their caretakers and of others. Their view of a medical situation, for example, may take on an “all-or-nothing” characteristic in the way they view their medical situation.

Their all-or-nothing thinking often gives rise to an exaggerated view in matters of health and of the physical symptoms of any medical illness. The threat of physical illness is exaggerated to dramatic, even terrifying proportions. The BPD patient feels that he or she is either completely well or deathly ill. When they seek medical treatment for a health problem, they may swing from great trust and an exaggerated “all-good” perspective to a catastrophic, “all-bad” perspective of their medical situation. This switch may be abrupt and may ultimately lead them to seek medical attention with a new doctor.

If the next physician ends up giving the same opinion, the BPD individual may become painfully disillusioned and may see themselves as being rejected, callously disregarded and abandoned to struggle with their illness alone. This can also play out as feelings of unworthiness. For example, they may feel that they are unworthy of their physician’s time or that the physician feels they are unworthy. Initially, BPD individuals fail to integrate their ambivalent feelings against the primary caretaker, but later this failure will generalize to other individuals and relationships as well.

They perceive many people as virtual caricatures that are either all good or all bad. Although family situations, genetic and biological factors contribute to borderline personality disorder, psychological factors are also believed to be involved. Kemberg (1975) suggests that BPD may result from the arrest of normal psychological development. In BPD individuals, the primitive defense mechanisms that are generally relinquished in early childhood are prolonged into adulthood.

Mahler (1971) and Masterson (1972) have hypothesized that borderline personality disorder results after a disturbance occurring in children between 16 and 25 months of age. The characteristic signs of BPD are excessive and pervasive instability of affect, self image and interpersonal relationships. BPD individuals are generally unable to regulate affect, particularly anger (Kemberg, 1975; Klein, 1977) and have an increased risk for major depression, substance abuse and ADHD. Depression and BPD appear to be related and are common in some families indicating that genetics may play a role.

Physical and sexual abuse, neglect, hostile conflict and the loss of a parent due to separation or death early in life are common events in the early childhood of BPD individuals. The borderline personality is five times more common among relatives of probands with this disorder than in the general population. Their personality instability interferes with or disrupts their family life, their working life and relationships, their long-term planning and their identity and sense of self. Once thought to be borderline psychotic, they are now viewed as having difficulty in controlling their emotions.

There is a high rate of self-injury without suicidal intent in borderline individuals (Soloff et al. , 1994; Gardner and Cowdry, 1985) as they are nonetheless prone to self mutilation. Part of their behavioral change may include recurrent episodes of suicidal behavior without suicidal intent, gestures and threats and they are sometimes given to self-mutilation behavior. Despite the lack of suicidal intent, they have a significant rate of attempted suicides. BPD patients are also very impulsive, often in a manner that can be potentially damaging or even life threatening.

Their impulsive nature generally involves at least two damaging or potentially dangerous behaviors such as excess spending, excessive gambling, substance abuse, frequent eating binges, reckless driving and excessive sexual behaviors, including unsafe sex. Their eating binges may also involve bulimia. BPD often occurs with most other personality disorders and can be difficult to distinguish from them. It shares many features common to mood disorder, dysthymic disorder, and cyclothymia and must be distinguished from them.

Borderline disorder is distinguished from identity problems because such problems are limited to a development stage. It is frequently diagnosed by excluding the typical clinical symptoms for other personality disorders. This distinction can be recognized based on the BPD individual’s efforts to avoid abandonment, unstable relationships plus their tendency to alternate between idealization and negative attitudes and affect such as devaluation, identity disturbance, impulsivity in potentially self-damaging areas, chronic feelings of emptiness, and inappropriately intensive anger or difficulty controlling anger.

BPD individuals generally have intense and unstable interpersonal relationships and their self-image and sense of self are markedly and persistently unstable. They often have chronic feelings of emptiness, are given to bouts of intense anger and have difficulty controlling anger. Often, their anger is inappropriately intense due to their very reactive moods. They are given to chronic feelings of emptiness. They can exhibit transient periods of paranoia and dissociative symptoms related to stress. These symptoms comprise nine general classes of symptoms of which most BPD individuals generally display at least five or more.

The general symptoms include 1) frantic efforts to avoid abandonment, 2) unstable and intense interpersonal relationships, 3) unstable self-image or sense of self, 4) damaging impulsive behavior, 5) self-mutilations and/or suicidal behavior, 6) unstable affect due to mood reactivity, 7) chronic emptiness, 8) inappropriate and intense anger and 9) dissociative or paranoid behaviors. BPD individuals may undermine themselves when attempting to reach a goal or even when close to reaching it, and they often feel more secure with inanimate objects and pets then in their interpersonal relationships. BPD individuals are prone to exaggeration.

Therefore, physicians treating the borderline personality should answer their questions with clear, non-technical answers. This will help to counter their elaborate fears as to how serious or life-threatening their health situation may be. The attending physician should be honest but not overly dramatic about their patient’s illness, the course of the illness, the case for recovery and the effects and side effects of treatment. Also, the physician should be careful to avoid encouraging the patient to idealize the care providers and should not fall prey to the patient’s denigration of other physicians and health care providers.

The patient needs to be reassured of the physician’s empathy for and interest in the patient. This may require more frequent checkups, closer monitoring and other precautions to reassure the patient, but the physician should be careful not to provide reassurance prematurely. If the patient reacts negatively towards his/her physician, the physician should tolerate such behavior so as to reassure the patient that he/she will not be abandoned leading to a self-fulfilling prophecy. What might cause BPD?

Perhaps there is no clear answer to this question, but many studies indicate that a combination of traumatic experiences and events early in life combine with certain biological factors to trigger or contribute to the condition (Sadock and Sadock, 2005). For the most part, the biological factors and the early traumatic events are of an emotional nature. Studies have repeatedly demonstrated that BPD aggregates in families. (Goldman, 2000) BPD can be complicated by symptoms of psychosis, including such situations as hallucinations, distortions of the individual’s body image, hypnagogic phenomena and distortions of ideas of reference.

These symptoms may arise in response to stress and result in premature death or physical handicaps from suicide, suicidal gestures and self-mutilating or self-injurious behavior. The ultimate outcome of their situation can vary. Even though their life and lifestyle are marked by chronic patterns of instability during their early adult years, many gradually tend to overcome their situation with advancing age. Although BPD individuals are often chronically unstable, the disorder does not necessarily deteriorate into schizophrenia. Werble (1970) and Carpenter et al.

(1977) have shown that BPD symptoms are present over long periods and lead to major disturbances in social functioning. They were not likely to get married and generally did not get much satisfaction out of life. In general, their quality of life was low. The symptoms of borderline individuals are similar to cyclothymic disorder, but differ in that cyclothymic patients have periods of hypomania. By the time they reach their 40s and 50s, BPD individuals generally tend to achieve a greater degree of stability in their relationships and the general functions of life.

Therefore, they are at greatest risk of suicide and physical damage during their early adult years when their affect is most impaired. As they grow older, their affect is generally less impaired. Borderline personality patients feel rejected and are subject to anxiety, depression and other forms of intensely unpleasant affect. Two methods more or less common in psychiatry are used to treat borderline personalities: Psychological treatment and drugs. Two psychological approaches dominate but there is some debate as to which is most effective.

One approach is a long-term psychoanalytic approach using psychotherapy with some supportive modifications. This approach seeks to develop trust early in the treatment process as treatment progresses to a deeper exploration. The second approach, also a long-term approach, is more reality-oriented psychotherapy that does not focus on unconscious fantasies, but attempts instead to provide structure and to prevent the deterioration caused by over stimulation sometimes seen in more insight-oriented approaches. Behavioral contracting is useful for setting limits with borderline patients (Selzer et al.

, 1987). Linehan (1987) has developed an approach designated dialectical behavior that combines behavioral interventions in a supportive framework. Beck and Fernandez (1998) reported on 50 studies of cognitive-behavioral treatment for anger management that can be applied to borderline personality disorder and found large treatment effect for this approach. As for the drug treatment, analysts generally resort to antidepressants, anti-anxiety and low doses of antipsychotic agents (the latter to be used during brief reactive psychoses) to deal with these problems.

Klein (1977) suggests using monoamine oxidase inhibitors BPD to treat patients who are sensitive to rejection. Mood-stabilizing and mood regulation agents such as lithium and carbamazepine may also be helpful. We can summarize what has been said by saying that BPD is a serious mental health condition that is characterized by a 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.

It generally occurs early in life and can be life threatening in that patients can cause self injury leading to death, but it can be managed with psychological treatment and drugs. Drugs used to treat BPD involve mood-stabilizing agents, antidepressants, anti-anxiety agents and occasionally antipsychotic agents. Even though their life and lifestyle is marked by chronic patterns of instability during their early adult years, many gradually tend to overcome their situation with advancing age. Thus, they are at greatest risk of suicide and physical damage during their early adult years when their affect is most impaired.

As they grow older, their affect is generally less impaired. References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: APA Press: 2000. Beck, R, and Fernandez, E (1998). Cognitive-behavioral therapy in the treatment of anger: A meta-analysis. Cog Ther Res, 22:63 Carpenter, W. T. , Gunderson, J. G. , and Strauss, J. S. (1977). Considerations of the borderline syndrome: A longitudinal comparative study of borderline schizophrenic patients.

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