What is Borderline Personality Disorder?
Imagine a Styrofoam cup filled with water with a small hole in the bottom, the water slowly leaking out. For a short period of time the cup is filled with water, but over time the water slowly leaks out, constantly needing replenishing. This is a common analogy used for a borderline personality disorder in terms of their emotions, and never being “filled up.”
According to the DSM-IV, borderline personality disorder is a pervasive pattern of instability to maintain successful interpersonal relationships, poor self-image, and very marked impulsiveness. Symptoms usually begin in early adulthood. Rejection and separation can be intensely profound for these individuals. They have a strong difficulty in being alone, and they have strong abandonment fears. They have grossly inappropriate rage and anger. In severe cases, they present with self-mutilating and suicidal behaviors.
As previously discussed in Peace and Healing, as with all personality disorders, personality disorders occur on a continuum. Although individuals may meet a lot of the diagnostic criteria for a borderline personality disorder, that does not mean they are a borderline personality disorder (BPD). These individuals move quickly through relationships. They can be very caring and giving to other individuals. However this is always contingent on the promise of something in return, that their partner will be there when they decompensate. There are strong shifts in self-image. They have a variety of goals. There can be sexual identity confusion. Their self-image is based on being bad or evil. At times they seem to be void of feeling, and are grossly apathetic.
Individuals with BPD will often display impulsivity in at least two of many areas: Excessive gambling, binge eating, substance abuse, frequent engagement in unsafe sexual practices, or reckless driving. Self-mutilation is fairly common, and attempted suicide is even more common, based on their need to gain the attention of the individuals they feel are rejecting them. When a successful suicide occurs, it is usually not intended, and occurs accidentally.
Psychotic symptoms are rare, but can occur. Undermining behaviors are very typical. For example, tearing up diplomas from schools or resumes before a job interview, tearing up wedding certificates, dropping out of school before graduation, or acting aggressively towards a loved one in an attempt to wound themselves.
There has been some evidence that a past history of and sexual abuse may lend to this personality disorder. However there are no long-term studies to validate that.
According to the DSM-IV, the prevalence of BPD is about 2% of the general population, and approximately 10% of individuals seen in outpatient mental health clinics.
What are the causes of Borderline Personality Disorder?
Causes of (BPD) are speculative and exhausting. Psychologists have spent years looking at overlapping data and commonalities with extreme cases. There is evidence that extreme dysfunctional parenting, and emotionally absent mothers as well as “blanketing” mothers can have an impact in this disorder. Placing children in “double bind” scenarios repeatedly, as well as physical abuse and or sexual abuse plays a role in inducing BPD symptoms.
Children often feel as if they have no escape. They feel trapped in their environment, fantasize about leaving. They begin to act out for attention, which they desperately crave; the lack of response leaves the child no choice but to up the ante. When the behavior becomes so severe, the problem is identified as the child with the problem. The cause is directly inadequate parenting, and often paired with neglect.
Again, there are many theories as to what is the direct cause of BPD. As professionals in the field we need to use caution, not a rush to judgment, and look at all contributing factors. An extensive family and social history is imperative to know what the individual went through as they reached their developmental milestones.
What are Symptoms of Borderline Personality Disorder?
According to the DSM-IV, BPD is described as a pervasive pattern of instability of interpersonal relationships, self-image and marked impulsivity beginning in early adulthood, and presenting in a variety of contexts. At least 5 or more of the following 9 criteria must be met:
- Frantic efforts to avoid real or imagined abandonment. This does not include suicide or self-mutilating behavior.
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance marked by persistently unstable images of self.
- Impulsivity in at least two areas that are potentially self-damaging, gambling, sex, substance abuse, reckless driving or binge eating. Note: This does not include suicidal or self-mutilating behavior.
- Recurrent suicidal behavior, gestures or threats, or self-mutilating behaviors.
- Affective instability due to marked reactivity of mood lasting usually more than a few days.
- Chronic feelings of emptiness.
- Inappropriate and intense anger or difficulty controlling anger, frequently displaying behaviors of temper and recurrent physical fights.
- Transient stress-related paranoid ideation or severe disassociative type symptoms.
Obtained from the DSM-IV, Diagnostic and Statistic Manual of Mental Disorders.
What is the Treatment of Borderline Personality Disorder?
In an ideal situation, treatment of a BPD is a minimal of one year of individual outpatient therapy. It is usually longer than that. Sessions are usually 45 minutes to one hour. This author usually contracts with the individual, again telling the patient at the beginning that there will be times of crisis, times she/he is not going to be happy with the therapy, and that they need to “stick it out.” Again, this is the ideal situation.
Medication in the form of SSRI’s and anti-anxiety medication is often advised and can be very helpful. In the beginning, it is very crucial that when medication is given out, that it be dispensed in small quantities. Since you are seeing the individual weekly, medication intake can be monitored. This reduces some risk of overdose and suicide attempts. More often than not, therapy will be greater than one year. There is a fairly high recidivism rate with borderline personality disorders. We do see when individuals reach their fifth or sixth decade of life, a lot of the behaviors do decrease in intensity.
Many therapists have referred to BPD’s as “little tornados that continuously plod through their lives every decade, touching down here and there, disrupting many relationships and tearing apart others’ lives.”. The higher an individual’s IQ, the better chance of introspection and quicker resolution with some of their issues. Ideally, there is a stage in therapy where, if an individual is single, it is very important for them to live a period of time on their own without any intimate relationships. There has to reach some level of acceptance of who they are as a person before there is ever going to be any improvement. This is a huge accomplishment, and can be a major turning point in therapy.
Group therapy can be effective. It is very important to have two leaders in the group. However, it is not recommended until all of the participants have spent some time in individual therapy, and have some awareness of where they are in terms of progress in their therapy, as it can become extremely disruptive and counterproductive if BPD’s start group therapy too early.