Borderline Personality Disorder (BPD)

Basic Information

The fear of abandonment, separation or loss lies at the root of borderline personality disorder, and those who suffer from this illness go to any lengths to maintain a submissive or dependent relationship with a caretaker or caretakers whom they perceive as being able to protect them from a world in which they have difficulty functioning in as an adult. Usually the borderline patient has been unable to obtain a stable social level in work and stable interpersonal relationships commensurate with their intelligence and abilities. Making the same mistakes over and over, they find they repeat errors of the past and act impulsively -- often changing careers, interests and friends or acquaintances -- to ill effect, and a basic lack of confidence in social skills, talent and independence remains. Emotions are scattered and the very people they have convinced of their incompetence and have manipulated into looking out for them become targets of angry outbursts which only further the patient's sense of isolation, insecurity and guilt feelings, and the patient sees him or her self in a negative light, often making extreme self-deprecating comments and sometimes "punishing" him or her self by self-mutilation, such as cutting, or by suicide threats to atone for "sinful behavior" and to elicit sympathy from others so that abandonment will be stalled. Sometimes, however, supporters of the patient will have had enough and withdraw, leaving the borderline personality in a state of depression and self-loathing. This usually passes in hours or days, however, and some equilibrium returns but the pathological thinking and behavior remains. Though the patient can usually separate reality from fantasy, the same impulsivity, self-doubt and changes of self-image continue to torment the patient. The patient tends to see things in black and white, including him or her self, and will often adamantly call him or her self "good" one day and "bad" the next. The variability of moods marks the main features of the patient. Outbursts of uncontrolled anger, irritability and depression are also markers. External events play a minor role, bringing on erratic, impulsive thinking and behavior. Mostly they spring from internal impulses, perhaps charged by the repetitive lack of functioning and continual setbacks. They generally attempt the same ineffective or failed strategies over and over, expecting different results, but the results are always the same. The cycle of self hatred and dependence continues and the borderline will often exhibit bizarre behaviors in the face of it -- behaviors that are self-destructive and punishing, as well as manipulative in the sense that here is the proof for others that the patient is unable to master the rudiments of self-care. Bizarre behaviors and thinking can include:

cutting, self-mutilation
drug addiction, alcoholism
reckless driving
agitated physical and mental state
angry outbursts "from out of the blue"
fear of impending disaster
episodes of bizarre thinking
occasional marked breaks with reality that usually resolve spontaneously
sexual excesses
unsafe sexual behavior
changes in sexual identity or gender
confusion
financial irresponsibility
hypochondria (to keep others empathetic)

Borderline personality disorder or BPD is a relatively new classification in DMS-III (1980 American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders"). Though symptoms of this disorder have been studied and written about by eminent psychiatrists and psychologists throughout this century and even before, it is believed that six million or more individuals in the U.S. have this illness -- two percent to four percent of the population. Women apparently are four times more likely to have BPD, although it is widely considered that men with BPD often go undiagnosed. Men with BPD may have had ADD (attention deficit disorder) as children.

The causes of BPD are not completely clear but it is thought that some cases can be caused by genetics, i.e. the patient is biologically vulnerable. Yet most cases (75%) are thought to stem from a chronic childhood psychotrauma -- a kind of continuing post-traumatic stress disorder.

Some psychiatrists feel that BPD is a more severe and chronic form of more moderate personality disorders such as the dependent, histrionic, compulsive and passive-aggressive, and diagnosis is often mixed, such as borderline-compulsive mixed personality. There is a great variance in behaviors with BPD patients who along with symptoms of BPD alone also have symptoms of the less severe personality disorders.

Symptoms

DMS-IV requires five or more of the following symptoms be present in order to diagnose BPD. These symptoms are paraphrased from DMS-IV:

going to any lengths to escape
abandonment
poor, unstable interpersonal relationships
uncontrollable anger
feelings of boredom, emptiness, loneliness
paranoid thoughts (temporary and stress-related)
intense moods or depression that can last for days
bizarre, self-destructive actions such as substance abuse
sexual confusion and excess
reckless driving
self-mutilation or suicidal thoughts or threats

Diagnosis/Treatment

In diagnosing BPD, a supportive therapist/counselor, experienced in working with patients with this illness, will be able to evaluate not only if the patient presents signs of BPD, but also:

a) if there are characteristics of the BPD that feature symptoms of other milder personality disorders, making a mixed diagnosis advisable b) where the patient rests on the scale or continuum of this disease, i.e. from what stage the patient is presenting symptoms (mild to severe range) c) what is the patient's pre-disposing background, i.e. can causes of this illness be identified

Treatment varies according to the severity of the illness. Developing a strong rapport and trust with the patient is desirable because a long term, intensive therapy is almost always indicated. BPD patients, because of their need for attention, care and dependency, will generally respond well to therapy but there is the danger that the patient will form a symbiotic relationship with the therapist and become so dependent on the therapist that even the idea of the therapist leaving for vacation can become extremely threatening because of separation anxieties and because they tend to see either the self or others as all-powerful. In these instances, the therapist could plan well in advance for absences (introducing a colleague who will substitute during the absence) while empathizing with the patient's fear of abandonment. Being firm in setting goals, without punishment, is important. Also, looking for signs of a possible breakdown is important, i.e. if the therapist sees signs of lasting depression, temporary hospitalization may be appropriate until the patient can regain equilibrium. Also, hospitalization is indicated in the face of suicide threats.

Improving the patient's ability to function is a primary aim, and antidepressant medication can be quite helpful in decreasing depression, reducing anxiety and minimizing self-destructive behavior. SSRIs (Selective Serotonin Reuptake Inhibitors) are usually beneficial. Also TCAs (Tricyclic Antidepressants) work on different neurotransmitters than the SSRIs and patients are sometimes treated with combinations of the two.

Strengthening self-image and interpersonal relationships are long-term goals and though there is rarely immediate marked improvement, over time if the patients can build a nurturing environment and improve personal relationships and make gains in functioning levels, the patient can live in the real world with some confidence. Also, any addiction issues, usually present in BPD patients, should be treated by a therapist versed in experience in recovery issues, must notably in the sexual addiction and substance abuse arenas. Group therapy and supportive twelve-step programs are available and important tools for recovery from most addictive behaviors.

If you have questions or concerns about borderline personality disorder, please consult with your health care provider.