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.