Today I return to write about one of my ‘favourite’ disorders or topics in Psychiatry; Borderline Personality Disorder (BPD) (Emotionally Unstable Disorder in ICD-10). The main features include instability of affects, self image, personal goals, interpersonal relations and a tendency to carry out self destructive, injurious or impulsive behaviors which include suicide attempts. Descriptions of individuals demonstrating BPD were first mentioned in medical literature almost 3000 years ago.
Initially, it was suggested that BPD is between or overlapped with:
- neurosis: a functional disorder in which feelings of anxiety, obsessional thoughts, compulsive acts, and physical complaints without objective evidence of disease, in various degrees and patterns, dominate the personality.
- psychosis: a severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality and the person may experience delusions and hallucinations.
Due to a high level of co-morbidity with other psychiatric illnesses, many perceived BPD to be a ‘wastebasket’ diagnosis with diagnostic precision and validity deficiencies, used when patients did not patently fall into other diagnoses. Furthermore, prognosis was thought to be ill-fated and unfortunately today a large number of mental health professionals still believe borderlines respond poorly to treatment despite increasing scientific research that opposes this consensus.
Studies have shown BPD to have diagnostic validity and integrity and some of these studies indicate that the disorder does not overlap with schizophrenia. Also, the disorder does appear to be a distinct diagnostic entity, although it co-occurs frequently with other mental disorders as seen in the table above.
To meet a diagnosis of BPD under the DSM-V, you must show ‘a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following’:
- Frantic efforts to avoid real or imagined abandonment
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Identity disturbance: markedly and persistently unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (e.g., substance abuse, binge eating, and reckless driving)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms
- The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations
- The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
- The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)
I aim to highlight the maladaptive inner experiences and pathological behavior of those suffering with this disorder in this post. By organizing them into 4 groups, an individual with BPD may be battling with:
People with BPD tend may be in a constant search for who they are. This can be seen in a vast number of life domains (i.e. home, family, style, profession, hobbies, relationships, friends, life principles etc). They may be indecisive and find difficulty in expressing their needs or principles when relating to others. Ambivalence may cause them to change jobs, activities and partners frequently. In cases of abuse, dissociation may contribute to the development of fragmentation, compartmentalization or ‘alters’ or personalities that are born during traumatic experiences and elicit a particular response. The difficulty with not knowing who they are and what they value can cause people with BPD to experience feeling empty, hollow and lost.
Emotions may repeatedly resurge and persist a long time. Consequently it may take longer than normal for people with BPD to return to a stable emotional baseline following an intense emotional experience. They are also prone to:
Emotional lability: Unstable emotional experiences and frequent mood changes can occur. They may be flooded with emotion then suddenly numb. Emotions are easily aroused, intense and/or out of proportion to events and circumstances. Extensive black and white thinking often turns disappointment into rage, which may be directed at others in physical attacks, bouts of anger, suicidal threats or self-injury.
Little/No Empathy: Compromised ability to recognise the feelings and needs of others associated with interpersonal hypersensitivity. Also, prone to feeling slighted or insulted.
Anxiousness: They may experience intense feelings of nervousness, tenseness or panic often in response to interpersonal stresses, worry about the effects of past negative experiences and future negative possibilities, feeling fearful, apprehensive, on the edge, threatened by uncertainty or fear of falling apart/ losing control.
Hostility: Persistent and pervasive angry feelings; anger or irritability in response to minor slights or insults, rejection or abandonment.
Separation Insecurity: Due to fears of rejection and abandonment from significant others. along with fears of excessive dependency and a complete loss of autonomy.
Depressivity/Dysphoria: Frequent feelings of being down, miserable or hopeless. Pessimism about the future, pervasive shame, feelings of inferiority, suicide and suicidal behavior. Whilst people with BPD feel joy intensely, they are especially prone to dysphoria, or feelings of mental and emotional distress with difficulty recovering from these moods.
Zanarini et al. recognized four categories of dysphoria that are typical of this condition: extreme emotions; destructiveness or self-destructiveness; feeling fragmented or lacking identity; and feelings of victimization. Within these categories, a BPD diagnosis is strongly associated with a combination of three specific states: 1) feeling betrayed 2) “feeling like hurting myself and 3) feeling out of control.
Splitting: Perception of things, others and themselves oscillate between all good or all bad. They may put someone on a pedestal only to topple them off it when they don’t meet their expectations. They may strive for perfection and feel at times they have achieved it, but may return to harsh self criticism when a mistake is made. They essentially lack trust in others, which is understandable when interaction with caregivers and others were abusive and inconsistent, thus they learnt not to trust and expect to be let down/abused.
Borderlines may feel entitled to special treatment and live outside rules and boundaries. Though, at times of low self esteem they tend to believe they are ‘bad’, ‘unlovable’, ‘not good enough’ and deserving of punishment. This defense mechanism disrupts the development of enduring perceptions of self and others. Abusive relationships may be comfortable to them as they are used to the chaos.
Projection: This defense mechanism causes them to attribute their own negative traits and behaviours to someone else. The borderline may wail ‘you don’t care about me’, when infact you just feel aggravated. The denial of her blatant misconduct may cause one to question their own perception of reality which can be crazy-making.
Intimacy issues: At times, perceptions of others are selectively biased towards negative attributes or vulnerabilities. Relationships tend to be intense, unstable and conflicted. Close relationships are marked by mistrust, neediness and anxious preoccupation with real or imagined abandoned. Splitting causes relationships to bounce between overinvolvement and withdrawal as the BPD idealizes and devalues their partner.
More females are diagnosed with BPD than males by a ratio of about 3:1, though some clinicians suspect that males are underdiagnosed. Nevertheless, there is a reason why females with BPD are dubbed ‘Women of Extremes‘. They tend to have issues doing things in moderation and find themselves on polar opposites most of the time.
Impulsivity: Disinhibition leads to substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending and reckless driving. Impulsive behavior may also include leaving jobs or relationships, running away, acting on a momentary basis without a plan or consideration of outcomes, lack of concern for ones limitations, denial of the reality with personal dangers, difficulty establishing or following plans and a sense of urgency and self harming behaviour under emotional distress.
People with BPD act impulsively because it gives immediate relief from their emotional pain or emergence of building tension. They tend to be risky with little regard for the consequences and are quite often ritualized. Inevitably they become irresistable and the cycle perpetuates despite feelings of shame and guilt that may accompany the aftermath. For borderlines, their acts may serve as mood stabilizers, a means to establishing a fragment of identity or a mode of escape from the emptiness and despair.
Self Harm and Suicide: Suicide is the ultimate conveyance of black and white thinking. The lifetime risk of suicide among people with BPD is around 10%. There is evidence that men diagnosed with BPD are approximately twice as likely to commit suicide as women diagnosed with BPD and considerable percentage of men who commit suicide may have undiagnosed BPD. Of those who die many were the most productive individuals with extremely high standards. Feelings of hopelessness and helplessness often follow perceived rejection or personal failure. Also, sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.
Self mutilation is common and a trademark of BPD, with or without suicidal intent. They may be visible, hidden, ritualistic, convey a special meaning, burns, cuts, scratches, penetrating wounds etc. The irresistible urge renders the act compulsive thus physical restraint is sometimes required to prevent injury in extreme cases. Accident-proneness may be a covert form of self-injury. Self injury may act as punishment for forbidden sexuality (e.g incest), a sacrifice to protect or ‘purify’ oneself, a cry for help, distraction from intolerable emotional distress, coded message to others, and reenactment of previous abuse.
Causes of BPD
As is the case with other mental disorders, the etiology of BPD is complex and not fully agreed upon. Evidence suggests that BPD and (PTSD) may be related in some way. Most researchers agree that a history of childhood trauma can be a contributing factor; 4/5 patients with BPD have a clear history of strikingly traumatic experiences. An overwhelmingly majority have been neglected, physically abused and a similar number have been sexually abused as children by caregivers of either gender or non-caregivers. Numerous patients have witnessed severe violence among others in their household and have been traumatized repeatedly in more than one way. They also report a high incidence of incest and loss of caregivers in early childhood.
Individuals with BPD were also likely to report having caregivers of all sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have neglected their child’s physical care.
Parents of all sexes were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were significantly more likely to report experiencing sexual abuse by a non-caregiver. Whilst some may suffer from severe functional impairment, there are high functioning borderlines who are more productive daily. Mediating factors include higher levels of executive functioning and a stable family environment.
In the 1980s, the first of a large number of neuroimaging, biochemical and genetic studies were published indicating that borderline disorder is associated with biological disturbances and reductions in areas of the brain involved in regulation of cortisol production, stress responses and emotion; affecting the hippocampus, orbitofrontal cortex and the amygdala, amongst other areas. The heritability of BPD is estimated to be 65%.
This suggests social factors (how a person interacts in their early development with their family, friends, and other children), psychological factors (individual’s personality and temperament, shaped by their environment and learned coping skills that deal with stress) alongside congenital brain abnormalities, genetics, neurobiological factors, and environmental factors contribute to the disorder.
Long-term psychotherapy is currently the treatment of choice for BPD. In 1993, Marsha Linehan introduced Dialectical Behavior Therapy (DBT), a specific and now well documented form of psychotherapy for patients with borderline disorder prone to self injurious behavior and who require and request frequent, brief hospitalizations. Since then, other forms of psychotherapy have been developed that are specifically designed for borderline disorder: mentalization-based treatment (MBT), transference-focused psychotherapy, schema-focused therapy and general psychiatric management.
The UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment and management of BPD recommends: ‘Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behavior associated with the disorder’. However, ‘drug treatment may be considered in the overall treatment of comorbid conditions” (i.e. mood stabilizers, anti-psychotics, anti-depressants, beta-blockers etc)
Over the past decade, two lay advocacy groups have been founded, the Treatment and Research Advancements Association for Personality Disorder (TARA APD), and the National Education Alliance for Borderline Personality Disorder (NEA- BPD). The missions of these organizations are: to increase the awareness of borderline disorder and its treatments; provide support to those suffering from the disorder, and to their families and friends; enhance the federal and private research funding dedicated to borderline disorder; and to decrease the stigma associated with the disorder.