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by Joel Paris, M.D.

What is Borderline Personality Disorder?

Personality disorders affect about 10% of the general population. This group of mental disorders is defined by maladaptive personality characteristics that have a consistent and serious effect on work and interpersonal relationships. DSM-IV defines ten categories of personality disorder. Of these, Borderline Personality Disorder (BPD) is the most frequent in clinical practice. BPD is also one of the most difficult and troubling problems in all of psychiatry.

The term "borderline" is a misnomer. These patients were first described sixty years ago by psychoanalysts who noted they did poorly in treatment, and therefore theorized that this is a form of pathology lying on the border between psychosis and neurosis.

Although we no longer believe that patients with BPD have an underlying psychosis, the name "borderline" has stuck. A much more descriptive label would be "emotionally unstable: personality disorder." The central feature of BPD is instability, affecting patients in many sectors of their lives.

Thus, borderline patients show a wide range of impulsive behaviors, particularly those that are self destructive. They are highly unstable emotionally, and develop wide mood swings in response to stressful events. Finally, BPD may be complicated by brief psychotic episodes.

Most often, borderline patients present to psychiatrists with repetitive suicidal attempts. We often see these patients in the emergency room, coming in with an overdose or a slashed wrist following a disappointment or a quarrel.

Interpersonal relationships in BPD are particularly unstable. Typically, borderline patients have serious problems with boundaries. They become quickly involved with people, and quickly disappointed with them. They make great demands on other people, and easily become frightened of being abandoned by them. Their emotional life is a kind of rollercoaster.

What Causes BPD?

We are only beginning to understand the causes of BPD. As in most mental disorders, no single factor explains its development. Rather, multiple risk factors, which can be biological, psychological, or social, play a role in its etiology.

The biological factors in BPD probably consist of inborn temperamental abnormalities. Impulsivity and emotional instability are unusually intense in these patients, and these traits are known to be heritable. Similar characteristics can also be found in the close relatives of patients with BPD. Research suggests that the impulsivity that characterizes borderline personality might be associated with decreased serotonin activity in the brain.

The psychological factors in this illness vary a great deal. Some borderline patients describe highly traumatic experiences in their childhood, such as physical or sexual abuse. Others describe severe emotional neglect. Many borderline patients have parents with impulsive or depressive personality traits. However, some patients report a fairly normal childhood. Most likely, any of these scenarios is possible. Borderline pathology can arise from many different pathways.

The social factors in BPD reflect many of the problems of modern society. We live in a fragmented world, in which extended families and communities no longer provide the support they once did. In contemporary urban society, children have more difficulty meeting their needs for attachment and identity. Those who are vulnerable to BPD may have a particularly strong need for an environment providing consistent expectations and emotional security.

Most likely, BPD develops when all these risk factors are present. Children who are at risk by virtue of their temperament can still grow up perfectly normally if provided with a supportive environment. However, when the family and community cannot meet the special needs of children at risk, they may develop serious impulsivity and emotional instability.

The Course of BPD

Borderline personality disorder is an illness of young people, and usually begins in adolescence or youth. About 80% of patients are women. BPD is usually chronic, and severe problems often continue to be present for many years. About one out of ten patients eventually succeed in committing suicide. However, in the 90% who do not kill themselves, borderline pathology tends to "burn out" in middle age, and most patients function significantly better by the ages of thirty-five to forty. The mechanism for this improvement is unknown. However, other disorders associated with impulsivity, such as antisocial personality and substance abuse, also tend to burn out around the same age.

The level of long term improvement in borderline patients varies a great deal. A minority will develop a successful career, marry happily, and recover completely. A minority will continue to be highly symptomatic into middle age. In the majority of cases, both impulsivity and emotional instability decline over time, and the patient is eventually able to function at a reasonable level.

BPD can be very burdensome for the patient's family. It is particularly difficult to deal with suicidal threats and attempts. Parents often wonder if they are at fault for the patient's condition and patients sometimes blame their parents, and some therapists will agree with them. However, the scientific evidence does not justify the conclusion that the family carries the primary responsibility for the development of borderline personality disorder.

The Treatment of BPD

There is no specific or universal method of treatment for BPD. At times, drugs can take the edge off impulsive symptoms. For example, some patients do better with low dose neuroleptics. However, no psychopharmacological agent has any specific effect on the underlying borderline pathology. In spite of the association between impulsivity and low serotonin activity, specific serotonin reuptake inhibitors (such as fluoxetine) rarely produce a dramatic improvement.

The mainstay of treatment for BPD has always been, and continues to be psychotherapy. However, because of their impulsivity, about two thirds of borderline patients drop out of treatment within a few months. Those patients who stay in therapy will usually improve slowly over time.

The chaos that characterizes border line patients makes them difficult cases for therapists. A patient with BPD may be continuously suicidal for months or years. Moreover, many of the same problems that patients have with other people arise in their relationships with helping professionals.

A number of different therapeutic methods have been tried with borderline patients. The largest clinical literature has come from psychoanalytically oriented therapists. Traditionally, psychotherapists focus on building a strong working alliance with the borderline patient. When the therapeutic relationship provides a safe haven, it is easier to work on developing better relationships with other people.

Most of the work in psychotherapy consists of helping patients to be less impulsive, and to exercise better judgment in their management of their personal lives.

In view of the frequency of reported childhood trauma in borderline patients, some therapists have suggested that BPD should be thought of as a form of post traumatic stress disorder. These clinicians tend 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.

Recent research suggests that cognitive-behavioral therapy, which has developed methods targeting impulsivity and emotional instability, may be particularly appropriate for borderline patients. Studies of a behavioral treatment specifically developed for patients with BPD, "dialectical behavior therapy," indicate that this approach can bring suicidality under control within one year. However, we do not know whether this method provides an effective long term treatment for the disorder.

BPD creates enormous suffering in those afflicted with it. Most patients describe a continuous state of emotional chaos, swinging from extremes of depression, anger, and anxiety. Borderline patients often need to feel suicidal in order to know that they can escape from their dysphoric feelings. The road to recovery in BPD is often long and difficult. However, borderline patients are often attractive and productive people. When treatment is successful, the patient, the therapist, and the family can all feel that it was well worth the trouble to see things through.

We need to conduct more research on the causes of BPD in order to develop more rational methods of treatment. In the future, we will probably have methods of pharmacotherapy and psychotherapy specifically designed for this challenging patient population. In the meantime, the best hope for most patients consists of linking up with a good therapist.

 

 

Joel Paris, M.D. is a professor of psychiatry at McGill University in Montreal, Cnnada. He is the author of a recent book on borderline personality disorder.

 

 

 

Borderline Personality Disorder

Borderline personality disorder is the most common personality disorder. It occurs in about 2% of the population. Symptoms usually flare up when a psychological stressor occurs, such as the threat of a break-up. When the stress subsides, the symptoms usually subside as well. People with borderline personality disorder may even experience brief periods in which they separate from reality. This disorder often overlaps with dysthymia (milder, longer lasting form of depression) and psychotic disorders. Nearly 90% of those with borderline personality disorder are also diagnosed with another personality disorder or major mental illness. The major characteristics of borderline personality disorder are:

 

Unstable personal relationships
People with borderline personality disorder fear abandonment and make desperate attempts to maintain relationships. However, their perception of relationships is so unstable that a friend can become an enemy over an ordinary disagreement.

Unstable self-image

This disorder is characterized by marked uncertainty in major life issues, such as life goals, sexual orientation, values, career choices, or types of friends.

Unstable emotions

Their emotional state can fluctuate dramatically from euphoria to intense anxiety to rage in a matter of hours or days. Typically, these emotional fluctuations are reactions to social interactions.

Little control over impulses

Reckless impulsivity may cause people with this disorder to act in self-destructive ways such as driving dangerously or bingeing on food, alcohol, or sex.

 

The diagnosis of BPD received much attention after the release of a film called Fatal Attractionin which a character played by Glenn Close (Alex Forrest) shows some of the above symptoms. Remember that Alex Forrest is fictional character and not an actual patient. Nor was this character based on a true story or an actual patient. The illness can manifest itself in many ways, but rarely is violence taken out on another person or animal as portrayed in the film.

 

Prevalence and Risks

Ten to 20% of psychiatric patients are diagnosed with this disorder. There are about three times as many women than men diagnosed with borderline personality disorder. Nearly 3/4 of borderlines attempt suicide or display self-mutilating behaviors like cutting themselves with razors or burning themselves. Only about 10% of suicide attempts are successful. Symptoms of borderline personality disorder and risks of suicide are greatest during young adulthood and seem to diminish later in life. Most people with borderline personality disorder achieve some stability in their life as they age.

 

Treatment

The goal of therapy is to reduce the frequency of borderline behaviors and allow the person to be more adaptive to society. The best therapeutic approaches to this disorder are still being debated. It appears that establishing a trusting relationship with a therapist who does not punish borderline symptoms has positive results. The therapist must actively participate in the therapeutic process by giving the client constant assurance and support while emphasizing the harmful effect of drug abuse, promiscuity, or other behaviors. Group therapy is an effective supplement to individual therapy allowing the person to express his or her feelings without fear of repercussions. It also provides social support and the opportunity to develop more meaningful relationships with people in or outside the group.

 

Medications have only been effective at improving moods and sometimes behavior. Doctors are still exploring the effect of antidepressants, antipsychotic drugs, and anti-anxiety drugs. These drugs appear to reduce symptoms of impulsivity, depression, and cognitive impairment, and perceptual impairment. Hospitalization may be necessary if the person is having suicidal thoughts and behaviors.

 

 

From Grief to Advocacy: A Mother's Odyssey

by Valerie Porr, M.A.

What do you do when the person you love the most on this earth is stricken with an illness that so completely changes her behavior it seems as though she has disappeared, leaving behind only a hollow shell; an illness that you know nothing about; that your friends don't believe exists; that professionals don't talk about; for which there is little or no explanatory literature; an illness which even Oprah doesn't discuss? Borderline Personality Disorder (BPD) is such an illness and is the diagnosis given to my only child.

At seventeen, my daughter ran away from home for the first time, revealing an intense hatred for me that she said she had nurtured for years. She accused me of child abuse. She was aided and abetted in this venture by a wealthy family who took her in, hired a lawyer for her and took me to court for control of her trust fund and her child support checks, all the while reciting a litany that she is still repeating. The court papers implied that I was the sick one and she was the victim who needed rescuing from me. I, on the other hand, had eight diagnoses from the various "reputable" therapists who had seen my daughter over the course of her adolescence. As it turned out, the previous professional observations were all stepping stones leading to a diagnosis of BPD. Sadly, this label explained both her history of impulsive behavior and her letters and diary entries I later found, wherein acts and feelings were revealed of which I was completely unaware.

Empowered by the court and further enabled by her hippie godfather, my beloved daughter walked out of my life. I have not seen her for over five years. She is now twenty three.

Grief has become a permanent part of my daily existence. Unfortunately, for those of us whose children are thus afflicted, we are denied the solace of the ordinary rituals and rites of mourning. We must learn to live with our loss and disappointment as others live with physical disabilities.

This edition of The Journal in some ways represents my personal odyssey over the past five and one half years in search of information, expertise and an effective form of therapy that will help to restore some semblance of the child I've lost-that can lift the gloom that pervades my life. On the pages that follow you will be introduced to people I have met, lessons I have learned, and circumstances that account for my evolution as a determined advocate for persons with BPD and for their families.

Bewildered and deeply saddened when my child left, I read every available book about BPD trying to understand and although I found the descriptions of the illness to be accurate, the explanations given did not coincide with my experiences with my daughter. Confused, feeling completely alone and hopeless, I started a support group for family members of people with BPD. As family after family joined our group and shared their histories, I found echoes of my own pain. It seemed we had all been accused of some sort of child abuse. That was the common denominator of most of our experiences. All of us had a child who either loved us or hated us, who had rage attacks and bouts of depression, who harmed themselves in myriad ways from self mutilation to attempted suicide to gambling to sexual addiction to eating disorders; who were impulsive, lacked emotional control or were substance abusers. In addition, these children of ours rarely perceived themselves as having a problem. To hear them tell it they were merely the victims of the behavior of others. The pain of seeing our children in this condition was magnified by the professionals who didn't or couldn't help them yet never hesitated to blame us for the problem. We, the parents, were made to feel like destroyers of those we had brought into the world, loved and nurtured.

At this point, through the efforts of a dedicated fellow advocate, John Grelek, I had the good fortune to learn about the work of Dr. Marsha Linehan of the University of Washington in Seattle. She had developed something called Dialectical Behavioral Therapy (DBT) - a system of cognitive behavioral therapy for the treatment of BPD with outcome studies showing its efficacy. Suddenly, in her work, I found some answers to my questions and, for the first time, I felt there was hope for my child and for others. It became my "mission" to bring Dr. Linehan's work into the New York City Mental Health System.

With the help of key people in the city and state mental health systems, and my loyal ally and mentor, Dr. Robert Trestman, in record time we applied for and got funds to bring Dr. Linehan to NYC for a two day training conference that was attended by 350 professionals. It was an extraordinary event, and one that Dr. Trestman and I agreed would require appropriate follow up to insure any real progress. With that in mind, we created an entity called TARA-APD-an acronym for Treatment and Research Advancement Association for Personality Disorder. As a non-profit organization it would be the voice that was needed for the support of those suffering BPD and contending with the conflicts in today's changing world of research and health delivery systems. We would no longer tolerate the indignities that people with BPD and their families had historically been subjected to by governmental and medical authorities who should know better.

As a child I had seen a film called "Gaslight" in which Ingrid Bergman, an heiress who is newly married, remarks to Charles Boyer, her ne'er-do-well husband, that the gaslights in their home seem to be dimming. "No, they aren't darling," says Boyer, as he fawns over her, "You are imagining things." Ingrid soon feels that she is going mad when, over time, what she perceives as reality is not being validated by her doting husband. The dimming gaslight is the perfect metaphor for the experience of living with someone with BPD, and advocating for education, appropriate treatment and research for this painful disorder.

The person suffering from BPD, a severe and persistent mental illness, may appear completely "normal" and may often have the ability to act "as if" he or she has no problems. In fact, many people with BPD become professional actors. This "as if" ability of people with BPD can be particularly devastating to those who love them.

I remember a night when my daughter locked herself in the bathroom after a rage attack. I called the police. She kept the police waiting outside the door for thirty minutes while I escalated to absolutely frantic concern. When she finally emerged, dissociated from her rage, she acted with regal serenity "as if" she were Grace Kelly. The police gave me that "raised eyebrow" look to which I have since become accustomed. It is a look all too familiar to families of people with BPD who feel foolish and embarrassed when authorities arrive to assist with a problem that now seems not to be there. It is "as if..."

If one combines the professional's attitudes toward people with BPD with the ability of a high functioning person with BPD to act "as if " - one is having dinner with Boyer and Bergman as the lights dim. The supportive family member is frustrated and confused by the patient's demonstration of the ability to effectively act out a denial of the illness, while the doctor minimizes or avoids it with dismissal comments like, "She's just a teenager. She'll outgrow it..." and the gaslights seem to dim, again.

The attitude of the psychiatric community towards BPD is very complex. Many professionals fail to recognize BPD or try to avoid making the diagnosis. It is a disorder-an illness-that polarizes professionals into non-professional behavior which can then be called stigma or counter transference or just plain "I can't stand this patient." The sense of frustration and of failure which professionals experience when treating people with BPD makes some feel uncomfortable, inadequate or ineffective. This is usually blamed on the patient and, of course, on the family - bad patients from dysfunctional families.

NAMI, the National Alliance for the Mentally III, doesn't include BPD in its advocacy efforts, as if they have decided "it is not a brain disease." Current research findings in neurobiology and psychopharmacology disagree with their unsubstantiated position, however, one can see how they justify it by pointing out that, until now, BPD has been omitted from most epidemiological studies, and the American Psychiatric Association, the National Institute of Mental Health, the Center for Mental Health Services, NMHA and NAMI have yet to produce even a brochure explaining BPD. This seems strange when you consider that BPD makes up 2% of the general population, 20% of the inpatients and 11% of the outpatients in the mental health system, has a 10% suicide rate and fills our prisons, divorce courts and civil courts. Thus I have become Ingrid Bergman, complaining that the lights are dimming while everyone looks at me with that "raised eyebrow." Should I tell the emperor he is naked while others are admiring his invisible new clothes?

The person suffering with BPD has a similar experience. Knowing that their treatment is inappropriate and their medication (generally thorazine) is not helping, they often quit treatment. Wouldn't you? They are then stigmatized, labeled treatment resistant and difficult patients. And so they are. Unless, of course you question the treatment offered by an antiquated mental health system that has not yet given up the gaslight for something more illuminating.

Living with the isolation that must accompany the experience of having BPD requires a great deal of courage and a very strong desire to survive. In 1994 the New York State Office of Mental Health Information Service reported only 297 borderline patients in the State of New York. Knowing these numbers couldn't possibly be accurate, Dr. Charles Swenson of NY Hospital Cornell Medical Center and I compiled a provider questionnaire. Out of 39 responses, 997 patients with BPD were reported. If you question any clinician or substance abuse counselor they will tell you how prevalent BPD is in their facility and complain about how hard this population is to treat. Lectures or workshops on BPD are always well attended. So many patients, families and providers are desperate for any information at all.

BPD patients are usually admitted to psychiatric hospitals through the emergency room after a suicide attempt. The patient usually makes four or five; one out of ten succeeds. These are tough odds. At a recent Suicide Prevention Conference not one of the presenters ever mentioned BPD. An esteemed researcher presenting his findings on adolescent suicide also omitted discussion of BPD. When I asked why he didn't mention an illness which effects so many adolescents, his response was, "Ah, yes. You're right, but it's a very difficult subject." Is that the gaslight I see dimming again? Because it is a difficult disorder, if we avoid discussing it, will it then, perhaps, go away? This professional avoidance is unacceptable to every parent or loved one of a person with BPD who lives in fear of that middle-of-the-night telephone call and to the parent whose child repeatedly tries to commit suicide.

And what solace is it for the family whose child has died. Yes, it's difficult! BPD can be fatal. Should we hush up and politely go away? Or do we go on till we have changed this professional denial of so serious and life threatening a problem? Yes, Dr. Esteemed Researcher, we agree "...it's a very difficult subject!" BPD is co-morbid with anorexia and bulimia. Those who suffer from lack of impulse control will often use food as a means of acting out. At lectures on eating disorders it is rare to hear a discussion of how to deal with the anorexic who has BPD. When I ask my usual questions, the faraway look wil1 come into the eyes of the presenter as he says, "Yes, we should be studying that, as it is related." The voice will then trail off as they quickly take another question. But, I persevere; I send them related research papers, I ask more questions, and I tell them about TARA -the Association for Personality Disorder. I pose questions at each and every lecture or workshop I attend. You can hear some say, "Oh, no...not her again!" Yes, there I am...somebody's relentless mother, asking researchers the questions practitioners are desperate to learn about and should be asking themselves. When I am not there, does anyone else bring up this stigmatized disorder? BPD is spoken of in hushed tones, with a tinge of embarrassment-like syphilis or TB, taboo diseases at the turn of the century, or like AIDS when it first came to the public's attention. If we continue to allow BPD to remain in the psychiatric closet we will never get our children the treatment they deserve. More questioners are wanted. More advocates are needed; a chorus of voices demanding that things change!

Males with BPD are prone to domestic violence and rage attacks. They make up a large percentage of the prison population and seem to be resistant to treatment as usual. A leading specialist in schizophrenia who writes on the conditions of the mentally ill in the forensic system and advises families to be aggressive advocates and provoke wolf-like - confrontations recently, unashamedly, described BPD as a "garbage bag diagnosis." I took his advice and advocated aggressively, with letters to him, and finally a confrontation with him-eyeball to eyeball, face to face. And what did he do, this champion I had admired from afar for his courage and knowledge on other issues? He promised me he would never again describe BPD in those terms. Be assured we will monitor the keeping of that promise. It appears that to be a successful advocate one must perfect the role of professional pest. That is what I have proudly become.

People with BPD can be helped by combining sensitive and up to date psychopharmacological treatment and effective new methods of cognitive therapy. This will keep patients out of expensive hospital beds and help them back into meaningful roles in the community. Why would our society choose to ignore what can work to help people whose neurobiological disorder causes them to wreak havoc on themselves, bring despair to their families, create problems in the work place, fill our prisons and jails, clog our courts with stalkers and lengthy divorce and child custody battles, and burn out therapists faster than our schools can turn them out?

Finding the answers to these questions will not be easy. But we are determined to play a prominent role in putting BPD on the neurobiological disorders agenda. Some days I feel like Sisyphus pushing a huge rock to the top of the mountain. But, with TARA-APD and the people whose articles and experiences you will read in this edition, I know, at last, I am no longer alone. We are a growing community of mutual interest. To raise money for research, to create a family data bank and share our insights and information, and to advocate, advocate, advocate will, some day soon, turn out those metaphorical gaslights and illuminate the path to better tomorrows.

Valerie Porr, M.A. is a co-editor of this issue of The Journal and Executive Director of TARA Association for Personality Disorder whose offices are at 23 Greene Street, NY, NY 10013.

 

 

Borderline Personality Disorder

Deb Martinson

Borderline Personality Disorder (BPD) is one of the most controversial diagnoses in psychology today. Since it was first introduced in the DSM, psychologists and psychiatrists have been trying to give the somewhat amorphous concepts behind BPD a concrete form. Kernberg's explication of what he calls Borderline Personality Organization is the most general, while Gunderson, though a psychoanalyst, is considered by many to have taken the most scientific approach to defining BPD. The Diagnostic Interview for Borderlines and the DIB-Revised were developed from research done by Gunderson, Kolb, and Zanarini. Finally, there is the "official" DSM-IV definition.

Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder: in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD. Others believe that the term "borderline personality" has been so misunderstood and misused that trying to refine it is pointless and suggest instead simply scrapping the term.

 

What causes Borderline Personality Disorder?

It would be remiss to discuss BPD without including a comment about Marsha Linehan's work. In contrast to the symptom list approaches detailed below, Linehan has developed a comprehensive sociobiological theory which appears to be borne out by the successes found in controlled studies of her Dialectical Behavioral Therapy.

Linehan theorizes that borderlines are born with an innate biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. They peak "higher" emotionally on less provocation and take longer coming down. In addition, they were raised in environments in which their beliefs about themselves and their environment were continually devalued and invalidated. These factors combine to create adults who are uncertain of the truth of their own feelings and who are confronted by three basic dialectics they have failed to master (and thus rush frantically from pole to pole of):
bulletvulnerability vs invalidation
bulletactive passivity (tendency to be passive when confronted with a problem and actively seek a rescuer) vs apparent competence (appearing to be capable when in reality internally things are falling apart)
bulletunremitting crises vs inhibited grief.
DBT tries to teach clients to balance these by giving them training in skills of mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation.

Kernberg's Borderline Personality Organization

Diagnoses of BPO are based on three categories of criteria. The first, and most important, category, comprises two signs:

 
bulletthe absence of psychosis (i.e., the ability to perceive reality accurately)
bulletimpaired ego integration - a diffuse and internally contradictory concept of self. Kernberg is quoted as saying, "Borderlines can describe themselves for five hours without your getting a realistic picture of what they're like."

The second category is termed "nonspecific signs" and includes such things as low anxiety tolerance, poor impulse control, and an undeveloped or poor ability to enjoy work or hobbies in a meaningful way.

Kernberg believes that borderlines are distinguished from neurotics by the presence of "primitive defenses." Chief among these is splitting, in which a person or thing is seen as all good or all bad. Note that something which is all good one day can be all bad the next, which is related to another symptom: borderlines have problems with object constancy in people -- they read each action of people in their lives as if there were no prior context; they don't have a sense of continuity and consistency about people and things in their lives. They have a hard time experiencing an absent loved one as a loving presence in their minds. They also have difficulty seeing all of the actions taken by a person over a period of time as part of an integrated whole, and tend instead to analyze individual actions in an attempt to divine their individual meanings. People are defined by how they lasted interacted with the borderline.

Other primitive defenses cited include magical thinking (beliefs that thoughts can cause events), omnipotence, projection of unpleasant characteristics in the self onto others and projective identification, a process where the borderline tries to elicit in others the feelings s/he is having. Kernberg also includes as signs of BPO chaotic, extreme relationships with others; an inability to retain the soothing memory of a loved one; transient psychotic episodes; denial; and emotional amnesia. About the last, Linehan says, "Borderline individuals are so completely in each mood, they have great difficulty conceptualizing, remembering what it's like to be in another mood."

 

Psychotherapy

Kernberg believes that psychotherapy for borderline psychopathology is designed to enhance the borderline patient's ability to experience self and others as coherent, integrated, realistically perceived individuals, and to reduce the need to use defenses that weaken ego structure by reducing the repertoire of available responses.  As a result, the patient may be expected to develop an increased capacity to control impulses, tolerate anxiety, modulate affect, sublimate instinctual needs, develop stable and satisfying interpersonal relationships, and experience intimacy and love.

Gunderson's conception of BPD

Gunderson, a psychoanalyst, is respected by researchers in many diverse areas of psychology and psychiatry. His focus tends to be on the differential diagnosis of Borderline Personality Disorder, and Cauwels gives Gunderson's criteria in order of their importance:

bulletIntense unstable relationships in which the borderline always ends up getting hurt. Gunderson admits that this symptom is somewhat general, but considers it so central to BPD that he says he would hesitate to diagnose a patient as BPD without its presence.
bulletRepetitive self-destructive behavior, often designed to prompt rescue.
bulletChronic fear of abandonment and panic when forced to be alone.
bulletDistorted thoughts/perceptions, particularly in terms of relationships and interactions with others.
bulletHypersensitivity, meaning an unusual sensitivity to nonverbal communication. Gunderson notes that this can be confused with distortion if practitioners are not careful (somewhat similar to Herman's statement that, while survivors of intense long-term trauma may have unrealistic notions of the power realities of the situation they were in, their notions are likely to be closer to reality than the therapist might think).
bulletImpulsive behaviors that often embarrass the borderline later.
bulletPoor social adaptation: in a way, borderlines tend not to know or understand the rules regarding performance in job and academic settings.

The Diagnostic Interview for Borderlines, Revised

Gunderson and his colleague, Jonathan Kolb, tried to make the diagnosis of BPD by constructing a clinical interview to assess borderline characteristics in patients. The DIB was revised in 1989 to sharpen its ability to differentiate between BPD and other personality disorders. It considers symptoms that fall under four main headings:
  1. Affect
    bulletchronic/major depression
    bullethelplessness
    bullethopelessness
    bulletworthlessness
    bulletguilt
    bulletanger (including frequent expressions of anger)
    bulletanxiety
    bulletloneliness
    bulletboredom
    bulletemptiness
  2. Cognition
    bulletodd thinking
    bulletunusual perceptions
    bulletnondelusional paranoia
    bulletquasipsychosis
  3. Impulse action patterns
    bulletsubstance abuse/dependence
    bulletsexual deviance
    bulletmanipulative suicide gestures
    bulletother impulsive behaviors
  4. Interpersonal relationships
    bulletintolerance of aloneness
    bulletabandonment, engulfment, annihilation fears
    bulletcounterdependency
    bulletstormy relationships
    bulletmanipulativeness
    bulletdependency
    bulletdevaluation
    bulletmasochism/sadism
    bulletdemandingness
    bulletentitlement

The DIB-R is the most influential and best-known "test" for diagnosing BPD. Use of it has led researchers to identify four behavior patterns they consider peculiar to BPD: abandonment, engulfment, annihilation fears; demandingness and entitlement; treatment regressions; and ability to arouse inappropriately close or hostile treatment relationships.

 

DSM-IV criteria

The DSM-IV gives these nine criteria; a diagnosis requires that the subject present with at least five of these. In I Hate You -- Don't Leave Me! Jerold Kriesman and Hal Straus refer to BPD as "emotional hemophilia; [a borderline] lacks the clotting mechanism needed to moderate his spurts of feeling. Stimulate a passion, and the borderline emotionally bleeds to death."

 

Traits involving emotions:

Quite frequently people with BPD have a very hard time controlling their emotions. They may feel ruled by them. One researcher (Marsha Linehan) said, "People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement."

1. Shifts in mood lasting only a few hours.

2. Anger that is inappropriate, intense or uncontrollable.

 

Traits involving behavior:

3. Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once

4. Two potentially self-damaging impulsive behaviors. These could include alcohol and other drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.

 

Traits involving identity

5. Marked, persistent identity disturbance shown by uncertainty in at least two areas. These areas can include self-image, sexual orientation, career choice or other long-term goals, friendships, values. People with BPD may not feel like they know who they are, or what they think, or what their opinions are, or what religion they should be. Instead, they may try to be what they think other people want them to be. Someone with BPD said, "I have a hard time figuring out my personality. I tend to be whomever I'm with."

6. Chronic feelings of emptiness or boredom. Someone with BPD said, "I remember describing the feeling of having a deep hole in my stomach. An emptiness that I didn't know how to fill. My therapist told me that was from almost a "lack of a life". The more things you get into your life, the more relationships you get involved in, all of that fills that hole. As a borderline, I had no life. There were times when I couldn't stay in the same room with other people. It almost felt like what I think a panic attack would feel like."

 

Traits involving relationships

7. Unstable, chaotic intense relationships characterized by splitting (see below).

8. Frantic efforts to avoid real or imagined abandonment
bulletSplitting: the self and others are viewed as "all good" or "all bad." Someone with BPD said, "One day I would think my doctor was the best and I loved

 

 

Promising Treatment for Borderline Personality Disorder

 

Dialectical Behavior Therapy, often referred to as DBT, is an empirically researched psychotherapeutic treatment developed by Dr. Marsha Linehan, Professor of Psychology, University of Washington, for patients struggling with chronic suicidality, intentional self-harm and borderline personality disorder (BPD). This therapy, employing cognitive and behavioral principles, is rapidly becoming a standard for treating borderline patients in both this country and abroad. DBT consists of two primary components involving individual psychotherapy once a week and a weekly skills training group. Additionally, patients are offered telephone consultations with their individual therapist as needed.

Biosocial theory. DBT is based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation. The disorder is characterized by heightened sensitivity to emotion, increased emotional in-tensity and a slow return to emotional baseline. Characteristic behaviors and emotional experiences associated with BPD theoretically result from the expression of this biological dysfunction in a social environment experienced as invalidating by the borderline patient. 

Although there are many examples of invalidating environments, all share three characteristics: (1) individual behaviors and communications are rejected as invalid; (2) emotional displays and painful behaviors are met with punishment that is erratically administered and intermittently reinforcing; (3) the environment oversimplifies the ease with which problems may be solved and needs met. Most of us have encountered such environments at some point in our lives and we commonly deal with them by changing our behavior to meet expectations, or by changing the environment so that it is no longer invalidating, or, ultimately, by simply leaving the environment. The dilemma for the borderline patient occurs when the individual is unable to meet expectations, cannot change the environment or cannot leave, thus experiencing what has been called a "double bind."

Treatment. The primary dialectic that defines the core treatment strategies in DBT is the tension between acceptance of the patient and the expectation that the patient needs to change. Acceptance strategies, drawn from Zen practice, involve emotional, behavioral and cognitive validation as well as teaching the patient personal strategies for validation. One example of a validation strategy would be recognizing how self-mutilation can be adaptive (i.e., useful for regulating emotion). 

The antithesis of acceptance is the expectation of change. This expectation is embodied in behavioral therapy with its emphasis on problem solving, rationality, logic and gaining knowledge by testing hypotheses. Strategies for promoting change include problem solving, contingency procedures, skills training, exposure and cognitive modification. 

An example of a problem-solving procedure is the use of a "chain analysis" to diminish cutting (self mutilation) behaviors. A chain analysis reviews the environmental and personal antecedents and consequences of the cutting behavior in mi-nute detail. An important goal of this procedure is to identify points during the chain of events when the borderline patient has an opportunity to do something different. This sets the stage for the patient to avoid the problematic behavior in the future.

DBT is organized along a fourfold hierarchy. The first priorities are suicidal or parasuicidal behaviors and ideation. The second priorities are behaviors that interfere with therapy. Third is behavior that interferes with quality of life. The fourth priority of DBT addresses skills deficits commonly found in individuals with BPD. 

The goals of skills training are to change behavioral, emotional and thinking patterns that cause personal misery and interpersonal distress. Specific goals include reducing dysregulation while increasing adaptive (i.e., more regulated) behaviors. Patients are taught to attend to the moment without judgment or impulsivity, a quality Dr. Linehan describes as "core mindfulness." Newly learned skills enable patients to improve emotional, cognitive and interpersonal functioning.

Empirical results. DBT was compared to treatment as usual (TAU), typically consisting of psychopharmacological treatment and intermittent supportive psychotherapy. In a landmark study, Linehan and colleagues found the following:

1. Compared with TAU, subjects assigned to DBT had significantly fewer and less severe parasuicidal behaviors during the treatment year. These results were obtained even though DBT was no better than TAU at improving self-reports of hopelessness, suicide ideation or reasons for living.

2. DBT was dramatically more effective than TAU in limiting treatment drop out, the most serious behavior interfering with therapy. At the end of one year, only 16.4 percent of DBT patients had left treatment. In contrast, approximately 50 percent of TAU patients had dropped out.

3. Subjects assigned to DBT had a tendency to enter psychiatric inpatient units less often and had fewer inpatient psychiatric days. Those in DBT had an average of 8.46 inpatient days over the year compared with 38.86 inpatient days for subjects receiving TAU. This finding suggests that DBT is cost effective.

4. DBT subjects rated themselves as more successful at changing their emotions and improving general emotional control. They also had significantly lower scores on self-reported measures of anger and anxious rumination.

In a subsequent study, the standard DBT (DBT individual therapy and the DBT skills group) was compared to a once weekly individual psychodynamic therapy and the DBT skills group. This study showed that the DBT skills group lost its effectiveness when combined with individual psychodynamic therapy. This study also supported the practice of providing telephone consultations to patients between sessions when needed. To explain this point, Linehan likens life to a basketball game — having a therapist unavailable between sessions would be like a coach being unavailable during the game.

DBT is usually considered a one-year treatment. In this time, the therapy targets behaviors involving life and death, behaviors that impede therapy and activities that affect quality of life. Concurrently, the patient learns techniques taught in the skills group. This one-year treatment has been empirically validated and designated as Stage I by Dr. Linehan; she has developed sequels to this treatment that are currently being evaluated. Stage II, which is begun only after the patient has acquired the basic skills of Stage I, is based on the rationale that patients must be able to cope with the consequences of trauma and focuses on reducing posttraumatic stress. Stage III emphasizes increasing self-respect, reducing self-hatred and achieving individual goals and interpersonal connections.

Additional Reading:

Linehan, Marsha M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press.

Linehan, Marsha M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York:
Guilford Press.

Linehan, M., Asuicidal borderline patients. Archives of General Psychiatry (1991). 48: 1060-1064.

Shearin, Edward N. and Linehan, Marsha M. Dialectical behavioral therapy for borderline personality disorder:  theoretical and empirical foundations. Acta Psychiatrica Scandinavica (1994). 89 (suppl. 379): 61-68.

                                                                      * * * 

This article was contributed by Elizabeth T. Murphy, PhD, and John Gunderson, MD. Dr. Murphy conducts outpatient DBT individual therapy and skills groups with patients at McLean Hospital. Dr. Gunderson is director of McLean’s Ambulatory Personality Disorder Service and Psychosocial Research Program, and is Professor of Psychiatry at Harvard Medical School.

Permission of McLean Hospital

 

 

Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a distinct disorder in it's own right. It is not, as many suppose, a 'diagnosis of degree'. To put it another way someone with a diagnosis of BP is not 'half a psychopath', nor is it valid to differentiate between the 'borderline' personality disorder and the 'full-blown'.

In part the confusion over the definition of BPD is a semantic one. The term borderline has associations with 'halfway' measures and so it is natural to assume that borderline personality disorder means half a personality disorder.

Actually the term refers to the now outdated but once widely accepted notion that sufferers exist on the borderline between psychosis and neurosis (Heller L. M. 1991). It is the BPD's propensity to exhibit both neurosis and pseudopsychosis which is the chief diagnostic paradigm.

Within this paradigm a number of clear diagnostic features are evident. The American diagnostic manual, DSM-IV, (American Psychiatric Association 1994) lists nine discrete features and requires five of these to be present over time before a diagnosis of BPD can be made. The nine features (reproduced in brief) are as follows:

1 Frantic efforts to avoid real or imagined abandonment.
2 A pattern of unstable and intense personal relationships.
3 Identity disturbance
4 Impulsivity in at least two areas that are potentially self damaging
5 Recurrent suicidal behavior, gestures, threats or self-mutilating behavior.
6 Affective instability due to a marked reactivity of mood.
7 Chronic feelings of emptiness.
8 Inappropriate, intense anger.
9 Transient, stress related paranoid ideation or severe dissociative symptoms.

The European version, ICD-10 (WHO - 1992) is largely in agreement with these criteria although less comprehensive in its' description of BPD.

Common features of Borderline Personality Disorder

Borderlines tend to experience chronic emotional lability and employ a range of endorphin releasing behaviors to compensate for their marked dysphoria. 

Self harm

One of the major features of Borderline Behavior is self-injury. Somewhat surprisingly for most people the act of cutting the flesh results in euphoria via the release of endorphins which not only prevents the sensation of pain but also anaesthetizes the BP against their chronic emotional distress. This is a major cause of self-harming behavior among Borderlines.

Mood swings

Emotional lability is a classic feature of BPD. Moods can shift rapidly - even minute to minute - with no obvious reason which the onlooker can understand.

Dysphoria

Possibly due to limbic system malfunction borderlines can experience a steadily intensifying combination of a range of distressing emotions leading to a range of anaesthetizing behaviors as noted above.

Psychosis

Progressive dysphoria, along with other stressors can give rise to psychotic or psuedopsychotic symptoms which are generally cognitive in nature (thought disorders) but can also include hallucinations, derealization and depersonalization.

Splitting

During development it is normal for children to categorize things as either 'all good' or 'all bad'. It is impossible for them to appreciate the 'gray areas' of life in the same way that adults can. This immature cognitive strategy persists in BPDs leading to rapidly changing and diametrically opposed opinions about life events and significant others. 

Co-morbidity

Because of their measurable brain dysfunction borderlines are also at increased risk of depression, anxiety disorders, other personality disorders and a range of behavioral and addictive disorders. The latter are secondary to the practice of self-anaesthetizing via impulsive or self-destructive behaviors. They are also prone to eating disorders, possibly as an attempt to assert control over themselves and their moods in much the same way as other eating disorder sufferers can. Bear in mind that eating disorders have also been related to sexual issues in development (Lyttle J. 1986 pp. 334 - 335). Incidentally, despite the psychotic features already outlined there is no correlation between BPD and schizophrenia.

Although there is general agreement concerning the diagnostic features of BPD its' aetiology and treatment have become the focus of considerable debate over recent years. 

Aetiology

In terms of aetiology the arguments can loosely be divided into the two familiar categories of 'nature' and 'nurture' and each argument has a lot to support it. A review of the relevant literature reveals, not unexpectedly, the traditional demarcation between psychiatry and psychoanalysis - a professional division which we as nurses are fortunate enough to be able to avoid in favour of a more eclectic understanding of the condition.

Regarding the 'nurture' argument statistical research has revealed a number of indicators of borderline development including:

1 "history of extreme frustrations and intense aggression during the first few years of life." (Kernberg O. 1975)
2 A history of 'invalidating environments' (Linehan M. 1993 2)
3 Sexual or physical abuse - particularly before age 15 (Herman et al 1989).

The concept of the invalidating environment is that of a situation fraught with erratic and inappropriate responses from significant others to the private experiences (thoughts, beliefs, emotions) of the developing BPD. In addition the rule of thumb in environments such as these is to oversimplify the ease with which problems can be solved, thus apportioning blame to the BPD who is criticized for their inability to easily overcome their difficulties. Over time this can result in a chronic and classical 'double bind' scenario.

The significance of physical and sexual abuse in childhood is emphasized by a number of separate studies: (Goldman S.J. et al 1992;Weaver T.L. et al 1993; Stone J. 1990). It should be remembered, however, that a history of Child Sexual Abuse is not a firm diagnostic criteria and there are many cases of BP who do not report such a history. Nevertheless it remains a remarkably common factor in the development of both male and female BPs.

These have led to some very relevant observations concerning the conditions' correlation with Post Traumatic Stress Disorder. Kroll J. (1988) suggested that the brief psychotic or psuedopsychotic interludes experienced by BP sufferers are no different from those of PTSD sufferers. It is also significant that research into PTSD using the Trauma Symptom Inventory (Briere J. 1997) correctly identified 89% of inpatients independently diagnosed as BP. Wether or not PTSD is a major component in the development of BP it is clear that many BPDs have significant psychological trauma in their histories.

Of course any discussion on the aetiology of BPD would not be complete without consideration of the other side of the argument - the 'nature' theory. Briefly, this area of research focuses upon the genetic or biological component of BPD. Teicher et al (1994) identified dysfunction in the limbic system, particularly relating to the hippocampus and amygdala although the research was unclear as to whether this dysfunction was the result of neurological changes secondary to abuse. 

"The Hippocampus .. is essential for the laying down of long term memory. The amygdala, in front of the Hippocampus, is the place where fear is registered and generated." (Carter R. 1998 p.42)

Given the essential functions of these two areas of the brain we can begin to understand the possible neuro-biological origins of certain Borderline traits such as emotional lability, splitting (the tendency to characterize things as 'all good' or 'all bad'), and the condition's dissociative traits. 

It is interesting to note that many researchers have identified serotonergic dysfunction in the brains of BPDs. This may have marked implications for the maintenance of mood and also go some way towards explaining the frustration and rage routinely exhibited by sufferers (Siever L.J. 1997).


Equifinality model

The equifinality model postulates that both the 'nature' and 'nurture' paradigms are equally valid. In brief it suggests that a biological vulnerability, perhaps inherited in BPDs with a family history of neurological disorder or created as a result of neurological changes secondary to PTSD in childhood is a necessary element of Borderline Personality disorder. The biological sequelae of childhood trauma is an area which we are only just beginning to understand. New studies suggest a wide range of neurobiological changes as a result of childhood sexual abuse (Siever L. J. 1997).

In addition to the biological factor, however it may arise, trauma of one kind or another does appear to be vital. This may be sporadic as is often the case in physical or sexual abuse or more chronic as already noted via the mechanism of Linehan's 'invalidating environment'. 


Treatment

It is no secret that this particular client group can be something of a nightmare when it comes to finding effective therapeutic interventions. The treatment of BPD is fraught with difficulty, particularly in an in-patient setting where many borderline behaviors result in discord among the staff or where the demands made upon an individual nurse can become extremely unrealistic.

Treatment of BPD falls into two main categories - pharmacology, incorporating a range of medication options and psychotherapeutic techniques ranging from supportive counseling to psychoanalysis. Although many of the treatments available fall firmly outside the remit of the RMN it does no harm for nurses to understand the options available.

Pharmacological treatments include:

SSRIs to combat the deficiencies in serotonin absorption.

Neuroleptics to treat psychotic symptoms as well as dysphoria .

Carbamazepine has been used in the treatment of behavioral and affective problems (Cowdry R.; Gardner D. 1988).

Thyroxin as many BPDs have symptoms of hypothyroidism
It has been reported that alprazolam can decrease behavioral control and that amitriptyline increases paranoia, assault and suicide threats (Cowdry R.; Gardner D. 1988).

Psychotherapeutic approaches to Borderline Personality Disorder are dogged with the same problems of compliance as pharmacological approaches are. This is in no small measure due to the difficulty Borderline patients have in forming the stable relationships generally seen as a pre-requisite for therapy.

Nevertheless 'talking cures' are effective in conjunction with medication and it seems that both types of intervention are necessary. If counseling is designed to help people think through their difficulties and learn to take control of and responsibility for their emotions it makes sense to give the brain a fighting chance to work properly at the same time. 

The most effective form of therapy for BPDs seems to be 'Dialectic Behavior Therapy' (Linehan M. 1993 2). This is at first glance a very strange juxtaposition of traditions drawing as it does from 'cognitive behavior therapy', 'supportive counseling' and 'zen Buddhism'. The term Dialectic refers to the inherent dichotomy of BPDs experience in which everything is polarised into extremes such as rejection/acceptance; good/bad; active; passive and crisis/calm. The term Dialectic refers to the scenario of opposing viewpoints characterized by thesis and antithesis in classical philosophy.

In essence the technique is designed to promote insight and change via skills training, introspection and validation. This in itself is seen as dichotomous as validation and acceptance in the mind of the BPD (black and white thinkers) is not conducive to encouragement to change.

The downfall for acute psychiatric wards is that the procedure typically takes 1 - 3 years and requires a consistent approach from two separate therapists who will (in certain circumstances) make themselves available to the BPD round the clock. Needless to say this is not a realistic option for ward based RMNs.

However many of the techniques of DBT are extremely valid and can be used in acute. In particular the principles of validation and skills training are very appropriate.

But herein lies the rub. If such an approach is to work it requires firm boundaries and a consistency of approach which is historically very difficult to maintain on acute. This is particularly true in the treatment of BPDs who can be adept at eliciting a range of responses from staff via the mechanisms of transference and counter-transference.

What we do have is the opportunity to promote self-acceptance and, in conjunction with medication prescribed by our medical colleagues, the chance to promote a range of skills from problem solving to anger management. It seems that BPD is less of a lifestyle choice than many of us, myself included, previously thought. There are very real psychological and biological/organic deficits which can be addressed and treated effectively.


REFERENCES


American Psychiatric Association (1994)
Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition (DSM-IV)

Briere J. (1997)
Psychological Assessment of Adult Posttraumatic States
American Psychological Association
Washington D.C.

Carter R. (1998)
Mapping the Mind
Phoenix
London

Cowdry R.; Gardner D. (1988)
Pharmacotherapy of Borderline Personality Disorder
Archives of General Psychiatry
Vol. 45

Goldman S.J. et al (1992)
Physical and sexual abuse histories among children with borderline personality disorder
American journal of psychiatry
149 (12) 1723-1726

Heller L.M. (1991)
Borderline Personality Disorder: New Management Concepts
http://www.biologicalunhappiness.com/
P. 2

Herman et al (1989)
Childhood trauma in Borderline Personality Disorder
American Journal of Psychiatry
151(2), 277-280

Kernberg O. (1975)
Borderline Conditions and Pathological Narcissism.
Jason Aronson

Kroll J. (1988)
The Challenge of the Borderline Patient
Norton & Company
New York

Linehan M. (1993) 1
Cognitive Behavioural Treatment of Borderline Personality Disorder
Guildford Press
New York

Linehan M. (1993) 2
Skills Training Manual for Treating Borderline Personality Disorder
Guildford Press
New York

Lyttle J. (1986)
Mental Disorder: its care and treatment
Bailliere Tindall
London

Siever L.J. (1997)
The Journal for the California Alliance for the Mentally Ill
Reproduced on the internet by
Mount Sinai School of Medicine
Dept. of Psychiatry
Via
www.mental-health-today.com
Stone J. (1990)
The Fate of Borderline Patients
Guildford
New York

Teicher et al (1994)
Early abuse limbic system dysfunction and borderline personality disorder
In Silk K.R. (Ed)
Biological and Neurobehavioural studies of Borderline Personality Disorder
American Psychiatric Press
Washington D.C.

Weaver T. L. et al (1993)
Early family environments and traumatic experiences associated with borderline personality disorder
Journal of consulting and clinical psychology
61(6) 1068-1075

World Health Organization (WHO) (1992)
International Classification of Diseases
World Health Organization
Geneva