Sanctuary for the Abused
Monday, March 19, 2018
Borderline Personality Disorder
Borderline personality disorder is a complex of problems that tend to be long-standing. Perhaps the real key to understanding BPD is to realize that the hallmark of this disorder is emotional instability, or even instability in general. This instability is manifest in many areas of a person's life.
1. People with BPD show marked shifts in mood, which often last only hours. One minute the person is apparently happy, the next the person is crying uncontrollably or is totally enraged.
2. Thus, another mark of mood instability is anger that is inappropriate, intense and/or uncontrollable.
3. The instability in behavior is marked by impulsive and often dangerous acts. Self-mutilation or suicidal threats and gestures are common among people with BPD. Many people with BPD say that cutting on themselves or burning themselves provides a sense of relief and calm that they have difficulty finding otherwise.
4. Other indications of instability in behavior is shown by potentially self-damaging impulsive behaviors: alcohol/drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.
5. In the area of identity, the instability is shown by marked, persistent identity disturbance: self -image, sexual orientation, career choice or other long-term goals; friendships, values. People with BPD often feel they do not know who they are or what they think or what their opinions are. Often they try to be what they think other people want them to be.
6. Such a lack of clear identity often leads to chronic feelings of emptiness or boredom.
7. Relationships for the person with BPD are understandably unstable, chaotic, and intense. These relationships are often characterized by what has been called "splitting". Splitting occurs when the self and others are viewed as all good or all bad. People with BPD tend to see the world in black and white terms, never grey. One minute the self or another person is seen as wonderful and the next, the self or the other person is seen as the devil incarnate. It seems like the person with BPD is unable to see the self or others in the full context of life. It doesn't really matter that yesterday you did something good. Only this moment's behavior counts in the evaluation.
8. Because of this inability to see things in context the person with BPD has difficulty seeing that others will continue to be involved with them. As a result, they become frantic to avoid real or imagined abandonment. "Just because you were my friend yesterday does not mean that you will be my friend today." To control these fears of abandonment, Borderlines often alternate between clinging and distancing behaviors. This phenomenon has been called: "I hate you, don't leave me."
Borderlines have a great difficulty in trusting people and themselves. They are hypersensitive to criticism or rejection and often feel they "need" someone else in order to survive. But since they do not trust others to stay and not abandon them, Borderlines show an extreme need for affection and reassurance by the other people in their lives.
Nevertheless, some people may have an unusually high degree of interpersonal sensitivity, insight and empathy, perhaps as a way to stay attuned to the signals given out by others of impending abandonment.
9. When under particular stress, the person with BPD may show transient, stress-related paranoid ideation or severe dissociative symptoms. In fact, a brief psychotic reaction can occur in which the Borderline experiences delusional thinking and hallucinations. This usually clears quite rapidly.
Other (non-DSM) characteristics:
As noted above, Borderlines typically have a lot of difficulty with what is called "object constancy." This is the realization that what a person was yesterday is a good predictor of what they will be today. Borderlines seem to have trouble seeing this. They do not trust that a person who was nice yesterday is likely to be nice today. It also extends to the concern that just because a person was here yesterday, does not mean they will be here today. As a result, the Borderline has considerable difficulty being alone. If you're not with me 100% of the time, how will I know you will stay with me?"
Boundary issues are also problematic for the Borderline. It is hard to place limits on others for fear of abandonment. The separation between "me" and "not me" are blurred.
Needless to day, because of all this instability in mood, identity, behavior and relationships, the person with BPD often leads a chaotic life.
According to Linehan (1993), the person who develops BPD is born with innate biological tendency to react more intensely to lower level of stress. They are temperamentally more reactive than other children. When such reactive children are raised in what she calls " an invalidating environment" the groundwork is set for developing Borderline Personality Disorder. An invalidating environment is one in which the thoughts, feelings and experiences of the child are negated by the adults in his/her life. For example, a child says "I'm sad" but the parent responds "No, you're not." This is an invalidation of the child's feelings. Over time, this leads to confusion in the child about the reality of his or her own perceptions of the world and self.
Many mental health professionals have found that a high number of people with BPD have experienced severe abuse as a child. In fact, some have gone so far as to assume that if a person is Borderline, they must have been severely abused when growing up. This has resulted in much blaming of families/parents. "However, the scientific evidence does not justify the conclusion that the family carries the primary responsibility for the development of borderline personality disorder." (Paris). Research has indicated that while many Borderlines have experienced severe abuse, not all have. It is therefore inappropriate to assume childhood abuse when presented with a person with BPD.
Low serotonin activity has also been implicated in this disorder but medications targeting serotonin levels do not seem very effective. It appears that BPD is more than simply a "chemical imbalance."
Borderline Personality Disorder usually begins in adolescence or youth. Diagnosis at this stage, however, should be done cautiously since many of the indicators of BPD are characteristic of "normal" adolescence.
There is a discrepancy between the rates of BPD in men and women, with 80% of sufferers being women. The reason for this is presently unknown.
One out of ten people with BPD will complete suicide. However, if they live long enough, BPD tends to "burn out" in middle age. Functioning seems to improve by the ages of 35 or 40 with some Borderlines being able to manage a successful career, family life, etc. A minority will continue to be highly symptomatic into middle age.
There is no specific treatment for BPD (PsychCentral). Medications may take edge off impulsive symptoms. Low doses of neuroleptics (antipsychotic medication) may be helpful. However, no pharmacological agent has any specific effect on the underlying borderline pathology.
Psychotherapy is the mainstay of treatment. However there is a high drop out rate from psychotherapy. When a borderline does stay in therapy, most of the work in therapy centers around decreasing impulsive behaviors and learning to exercise better judgment. Cognitive-behavioral therapy, particularly Linehan's Dialectic Behavioral Therapy, which targets impulsivity and emotional instability has been shown by research to be highly effective at least in the short term (i.e. 1 year).
Since many clinicians believe that BPD is caused by traumatic childhoods, there has been a tendency to focus on uncovering negative events so as to help patients "process" them. "However, there is no evidence that these methods are successful. In fact, there is some reason to suspect they can make patients worse by focusing too much on the past, and not enough on the present. In addition, borderline patients can be particularly prone to develop false memories in psychotherapy"(Paris).
Because of the risk of suicide, clinicians often use contracts to help ensure that the client does not commit suicide. However, hospitalization may become necessary if the risk becomes too great. Hospitalization is typically short-term and focused on reducing the risk of self-harm.
Support groups can also be of benefit for the Borderline. However, care should be taken that the instability of one Borderline does not "feed" the instability of another. This is a phenomenon that has been seen often in hospital settings where one borderline cuts herself and afterwards, several others start doing the same thing.
Because of the myriad symptoms shown by a person suffering from BPD, there is a risk that the person will be misdiagnosed. With a focus on the instability of mood, Borderlines are often called "Bipolar." If the focus is on the brief psychotic symptoms, the person may be diagnosed as "Schizoaffective." Such misdiagnosis can lead to inappropriate or over-medication by physicians.
Living with a person with Borderline Personality Disorder is painful and distressful. Finding a support group or even consulting a mental health professional may be helpful in dealing with this disorder.
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Linehan, M.M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guildford Press.
Paris, J. "Borderline Personality Disorder" in The Journal
PsychCentral. "Borderline Personality Disorder."