Borderline Personality Disorde Essay, Research Paper
BORDERLINE PERSONALITY DISORDER
Copyright 1999 John M Rathbun MD
DEFINITION – a pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsiveness, beginning by early adulthood and present in a variety of contexts
HISTORY:
* this diagnosis has been used over the past 30 years to label patients who get therapists upset.
* BPD has become the most diagnosed and researched personality disorder.
EPIDEMIOLOGY:
* two or three per cent of the general population are affected
* most common personality disorder in clinical settings
* diagnosed in 11% of psychiatric outpatients, 19% of inpatients, and about half of all personality disordered patients
* three times as common in women as in men
* five times more common in first degree relatives of affected persons
ETIOLOGY:
* well over half are victims of physical and/or sexual abuse
* dysfunctional family dynamics are common
* mothers often erratic and depressed
* fathers often absent or have major character problems
* early losses common
* genetic data implicate constitutional factors
DIAGNOSIS:
* typically present with dependent behaviors, seeking nurturance, closeness, and assistance
* within a therapeutic relationship, show escalating need for support
* when frustrated, show rage and devaluation of therapist
* relationships typically unstable, intense, and stormy
* they show extremes of idealization and devaluation
* may become extremely ill and self-destructive in reaction to fear of abandonment
* commonly have other personality disorders, mood disorders, substance dependence, bulimia, and PTSD
DIFFERENTIAL:
* Compared to cyclothymic and bipolar patients, BPD more reactive, angry in reaction to frustration in dependent relationships, with chronic feelings of emptiness
* compared to depressive disorders, BPD more manipulative in their suicidality and have poorer relationships
* compared to psychotic disorders, BPD have brief, reactive psychotic symptoms, not chronic, persistent ones
COURSE:
* typical BPD emerges in adolescence
* BPD especially severe in twenties
* about half improve spontaneously in thirties and forties
* BPD commonly fail in education, employment, and relationships
* suicide claims eight to ten per cent; many more carry scars of self-mutilation
MEDICAL TREATMENT:
* SSRIs and mood stabilizers help impulse control and moodiness
* antipsychotics help ideas of reference and brief psychotic symptoms (newer antipsychotics especially olanzapine)
* benzodiazepines and MAC’s make things worse
PSYCHOTHERAPY:
These are difficult psychotherapy patients. They have a lot of turbulent emotion in relation to the therapist, and they act out in ways that endanger them and irritate the therapist. Therapists are tempted to reject or indulge BPD.
It often takes five or more years of intensive individual psychotherapy to resolve BPD.
The therapist must be consistent and reliable, with excellent boundary management.
These patients routinely induce splitting in treatment teams.
They will not progress in therapy if currently being abused; they may under-report or over-report abuse.
These are not cases for the beginner, and student therapists should have intensive supervision when working with borderlines.
A DYNAMIC FORMULATION:
Ego States Theory was developed to explain why some adults intermittently behave like children. According to Ego States Theory, we all start out life as a collection of unintegrated ego states, such as “Happy baby”, “Hungry baby”, “Scared baby”, “Mad baby”, and “Sleepy baby”. We observe normal infants making abrupt switches between these ego states according to their current circumstances, and there seems to be little continuity of memory from one such ego state to the next. We observe normal parents sponsoring integration of ego states in normal youngsters. The preschooler who falls and hurts himself while playing undergoes a switch from the “Happy child” ego state to the “Scared and painful” ego state, and seems to have no idea that his suffering is a temporary condition. Mother provides reassurance along the following lines: “You’re OK now, even though it hurts; you were happy a few moments ago, and you’ll be happy again in another few minutes!” We can later observe the same child in grade school getting hurt, starting to switch ego states, and then reassuring himself that he’ll feel better soon, thereby maintaining his own ego integration. In adulthood, the fabric of ego integration is usually so tightly woven that it takes a catastrophe to cause dissociation of ego states.
Some children, however, don’t have a “normal” childhood with the support of well-integrated parents. Suppose father is alcoholic: he may come home drunk and rape the little girl, and the next day he may not remember what he did. Mother may be physically or psychologically absent from what’s going on with her daughter, so father is her only source of comfort. The child may be unable to get help for a variety of reasons, including her fear of father, fear of losing her father, and a sense that what’s happening is inevitable. She faces an endless series of irreconcilable realities.
Her best defense may be to maintain two distinct ego systems, one of which deals as best she can with father the rapist, the other with everyday living. The defense of dissociation permits the child to avoid thinking about the abuse so she can have as normal a life as possible.
When this sort of childhood starts early and goes on a long time, the ego states may accumulate very different memories, emotions, and behaviors. They may even have different names for themselves: one name representing the angry, hurt, sexually aware part, and the other designating the innocent child in her public persona.
A child growing up in a very sick family system faces a large number of insoluble problems, and dissociation may become the preferred way to deal with virtually every conflict the child faces. Thus, a system of dissociated ego states may arise, one of which does well in school, another is very athletic, a third feels a great deal of rage, a fourth can function sexually, and the fifth goes to church and prays a lot – thus fully expressing all the family values in one person without having to resolve any of the conflicts that divide the family.
Most borderlines report growing up in family environments that were
UNSAFE – abusive, threatening, unstable
DEPRIVING – rather than nurturing
HARSHLY PUNITIVE – often following inconsistent or invisible rules
SUBJUGATING – punishing child’s normal expression of needs and feelings.
Therefore, the borderline patient may usefully be viewed as a collection of relatively unintegrated ego states, whose dysfunctional behaviors and emotions constitute the presenting signs and symptoms. They differ from DID in that complete amnesia between ego states is not seen in BPD as in DID. They differ from PTSD in that intrusive recollections are less prominent in BPD than in PTSD. However, there’s considerable overlap in the origins, signs, symptoms, and effective treatment paradigms for DID, PTSD, and BPD; if you are successful with one of these groups, you’ll likely do well with the others.
I find ego states theory helpful in understanding dissociative disorders, PTSD, and BPD. Ideas about dissociation have become very controversial, however. Many psychologists are strongly opposed to the idea that traumatic memories can be lost and then reemerge. I find these criticisms ignorant, corrupt, and absurd.
They are ignorant in that they persistently confuse dissociation and repression in statements like, “There’s no evidence for repressed memories!” DISSOCIATION is a theory introduced by Pierre Janet, who observed patients with various sorts of hysterical illness to be cured when they recalled traumatic events that were symbolically connected to their symptoms. Janet’s work came before that of Sigmund Freud, who initially endorsed Janet’s ideas, then proposed his own theory of REPRESSION. What is repressed in Freud’s theory is a girl’s unacceptable wish: to replace mother as father’s love object. This wish is both denied and gratified in a SCREEN MEMORY: that father initiated sexual activity with the child. In other words, REPRESSION leads to remembering trauma that never happened, while DISSOCIATION is the forgetting of trauma that DID happen. Any so-called expert who confuses these two antithetical theories is not worthy of serious attention.
Many of the critics of dissociation are corrupt, in that they are associated with an organization that exists mainly to assist persons accused of sexually abusing their children to escape prosecution.
Finally, criticisms of dissociation are absurd, in that they allege that memory is fallible in only one direction. They claim that real trauma can never be forgotten, but that overzealous therapists often create memories of trauma that never happened through their suggestive techniques. These concerns are based on a small number of cases studied by one particular psychologist who observed contrived situations with little relevance to clinical reality.
The “recovered memories” controversy is heated and serious in its implications; it’s well for therapists who treat trauma victims to be keenly aware of the major issues being debated, to avoid hypnotic and other suggestive techniques, and to steer clear of prosecutions based on recovered memories unsupported by other convincing evidence.
THERAPEUTIC TECHNIQUES:
The basic techniques that have been found useful in dissociative psychopathology, whether PTSD, BPD, or DID, emphasize the following common therapeutic factors
1. development of continuity of memory across ego states, leading to improved integration of behavior, affect, sensation, and knowledge
2. a more thoughtful approach to decision making should replace dysfunctional behavior patterns which are impulsive and emotionally driven
3. appropriate expression of affect is facilitated in a therapeutic setting, with attention to parallel development of a repertoire of healthful self-soothing behaviors
4. the patient is encouraged to experiment with new patterns of behavior which will be more effective in getting the patient’s legitimate needs met
5. the patient is given the opportunity to use the therapist as a role model for a more healthy adult lifestyle.
To assist the therapist in maintaining appropriate engagement with borderline patients, a psychologist at Columbia named Jeffrey Young has developed an interesting way of categorizing the ego states commonly seen in borderlines. In his experience, the borderline patient will normally present four ego states, which he calls MODES:
1. The patient normally presents for therapy in an ego state which Young calls The Vulnerable Child Mode – in this mode, the patient is compliant and seeking assistance. This is a continuation into adulthood of behavior patterns used by most children to secure caring and assistance from powerful adults. The therapist will be idealized by the patient in this mode, often leading to a breakdown in normal therapeutic boundaries if the therapist’s grandiosity or guilt can be hooked by the patient. Since the borderline’s need for emotional nurturance exceeds the capacity of even the most giving therapist to satisfy, the therapist who lacks good professional boundaries will often begin to experience anxiety and resentment about the patient’s escalating demands. This will cause a failure of empathy on the therapist’s part, leading to the emergence of
2. The Angry Child Mode – in which the therapist is harshly devalued by the patient. If the therapist reacts defensively, an even more dysfunctional ego state will emerge:
3. The Punitive Parent Mode – since the child was punished for expressing normal needs and emotions, the adult knows that she is wrong to have these needs and emotions, and deserves punishment for expressing her feelings. Because she has internalized her parents’ dysfunctional attitudes and behaviors, she will begin to punish herself for having needed the therapist so much, and for having expressed her anger at the therapist for not satisfying those needs. In the punitive parent mode, the patient will derogate herself during internal dialogues, will experience herself as defective, worthless, and contemptible, and will often punish herself through self-mutilating or self-poisoning. Her attempt to regain a position of emotional equilibrium will often lead to the fourth and last of the common ego states seen in borderlines:
4. The Detached Protector Mode – in which feelings are disavowed, and the patient appears passively compliant and placid. This particular ego state is often overvalued by naive therapists whose personal insecurity leads them to prefer the appearance of calm to the turbulence of the patient’s other ego states.
The Detached Protector Mode is actually the least workable of the four ego states commonly seen in borderline patients; the only appropriate therapeutic technique for this mode is to encourage the Vulnerable Child mode to reemerge. One can do this by reminding the patient how she felt in a previous session.
You may then have to work through eruptions of the Punitive Parent Mode by assuring the patient that her need for nurturance is normal and acceptable. In general, your goal is to extinguish the Punitive Parent Mode by presenting yourself as a more accepting and appropriate parent for the patient.
The Angry Child needs help learning how to express that emotion in nondestructive ways. A therapist who is personally secure will encourage the patient to verbalize even more anger at the therapist, but actual verbal abuse should be redirected into more authentic emotional expressions. In this regard, the patient can be helped to use “I” statements rather than “you” statements – “I felt abandoned by you” rather than “You’re a cold, uncaring, heartless bastard”. You may have to assist the patient to understand that “I think you’re a cold, uncaring, heartless bastard” is really a “you” statement disguised as an “I” statement. The payoff for the patient in learning how to verbalize anger more appropriately is that the patient can then be angry without sacrificing connection with potential sources of emotional nurturance.
The Vulnerable Child Mode is the most workable ego state in borderline patients. Young suggests four basic techniques for this ego state:
1. Cognitive interventions – using journaling, you can teach the patient to examine her dysfunctional thoughts and decide for herself if they are valid. Some common dysfunctional assumptions in borderlines are
a. The world is dangerous and wants to hurt me
b. I am powerless in this world
c. I am hopelessly defective
d. Things are good or bad, choices are all or nothing
2. Experiential techniques – such as gestalt, imagery, and inner-child work
3. Therapeutic relationship – giving the patient a good example to imitate
4. Behavioral pattern breaking – finding new and more effective ways to get legitimate needs met
Some basic therapeutic techniques to use with borderlines:
1. validate needs and feelings; avoid problem-solving for the patient
2. be reliable and caring and real
3. strongly praise any improvement in behavior
4. re-attribute parental rejection to parental defects
5. teach the patient to recognize the various ego-states or modes of behavior as they emerge in the sessions, and to understand how their dysfunctional assumptions arose naturally from their suboptimal early experiences
5. attribute any patient failures to the patient’s excusable misunderstandings and help the patient to analyze these
6. using the empty chair technique, teach the patient how to talk back to the punitive parent
7 acknowledge your mistakes and model forgiveness of yourself and others
Most therapists who write about treatment of post-traumatic syndromes emphasize that treatment must proceed in stages. The first stage is always focussed on the development of a therapeutic relationship based on mutual understanding and respect. Young suggests this stage will be facilitated if the therapist can always think of the patient as a needy, primitive child rather than as a greedy, manipulative opportunist. Emergence of such negative attitudes in the therapist is associated with poor treatment outcomes, as the patient’s original experience with a punitive parent is repeated in the therapy.
It is important that patient and therapist agree on goals for the treatment in language that makes sense to the patient. It will also be necessary for the therapist to make clear the limits of therapist availability. Most patients with BPD have daily and nightly emotional crises, and will need frequent reassurance by phone or in extra sessions, at least until they learn how to manage their emotions better. It’s legitimate to tell the patient that daily phone calls are not OK, and that late night calls make you cranky the next day. You can also mention that learning self-soothing is one of the important goals of therapy.
If the patient is doing something that you can’t tolerate, it’s important to discuss this in session before you reach the point of resenting the patient. It’s appropriate to tell the patient that frequent phone calls disrupt your personal time, and that you may begin to feel resentful if it continues. Borderline patients have usually grown up around people with poor conflict resolution skills and poor interpersonal boundaries, so you want to show the patient how two adults can discuss and resolve a conflict without becoming abusive or withdrawn from each other.
When your practice situation permits, it’s appropriate to inform the patient that you charge for after hours phone contacts as well as for extended phone contacts during office hours. These are professional services which the patient should expect to pay for, just as you would expect to pay for the furnace man to come and relight your burner on a cold winter’s night. Offering unlimited free support at all hours of the day or night is a recipe for therapist burnout and for a major betrayal of the patient’s trust, because you will not be able to keep it up, and a burned-out therapist is both unhappy and dangerous.
Since many of you work for not-for-profit agencies, let me take a moment here to disparage certain dysfunctional attitudes that seem to pervade such organizations. You probably went into this sort of work because you enjoy helping people, and you feel real compassion for those less fortunate. These traits make you willing to work long hours for low pay, and your professional reputation depends on your willingness to go the extra mile for your clients. When an entire organization is staffed from top to bottom with professionals who share the value of self-sacrifice, there’s an opportunity for the best intentions to lead to the worst outcomes.
Not only does your borderline patient need to see that relationships can have limits and still be rewarding, she also needs to believe that she can survive on her own adult resources in this world. The therapist who can’t limit the patient in her quest for constant reassurance is saying, “Yes, you really are just as incompetent as you feel!”
The most challenging aspect of therapy with BPD is knowing how to set and enforce limits. This is a matter of therapeutic art, and cannot be taught in a lecture or manual. We all make errors in judgement when it comes to enforcing limits and providing optimal levels of support in therapy. More experienced therapists are less likely to make these errors, and should be sought as mentors by less experienced therapists. Therapeutic technique is not perfectible, only subject to endless improvement. Borderlines are those patients who show us where we have room to grow in our technical skills.
Important areas for limit setting in BPD:
1. rules for outside contacts
2. abusive behavior in sessions
3. client must agree to attend one more session before quitting (implies no impulsive suicide)
4. missed sessions must be planned (charging for no-shows and late cancels, except in extraordinary circumstances, is good for the patient)
5. patient must contact therapist before destructive acting out
6. “If you make me hospitalize you involuntarily, I won’t work with you after discharge”
Note that the threatened loss of the therapeutic relationship, once established, is the most potent adverse consequence available.
Dealing with the borderline in crisis:
a. find out what mode they’re in and respond appropriately
b. increase visits, even a few minutes every other day can help
c. assess suicidality: plan, intent, timetable, available means, any steps taken, past history, substance abuse
d. get permission to talk to significant others and arrange increased support
e. consult with another professional and document it
f. consider referral for medical therapy
g. consider day hospital or support group
h. consider brief hospitalization
If you’re interested in a more complete protocol for the treatment of BPD, and one with some actual outcome research to recommend it, you should look at two books published in 1993 by Guilford Press, both written by Marsha M Linehan: Cognitive-Behavioral Treatment of Borderline Personality Disorder, and Skills Training Manual for Treating Borderline Personality Disorder. Linehan’s method is briefly outlined in Guilford’s Clinical Handbook of Psychological Disorders.
Linehan calls her method Dialectical Behavior Therapy, because she emphasizes training the patient to abandon simplistic ways of thinking. She correctly points out that reality is complex and multifaceted, and that we all have to deal with situations involving conflicting and ambiguous data. An overall therapeutic goal of Linehan is to teach the patient to avoid rigid thinking and extreme behavior.
Linehan emphasizes that the therapist must respond hierarchically to the many challenges presented by borderlines. Suicidal behaviors have the highest priority for therapist attention, followed by therapy-interfering behaviors, then quality-of-life interfering behaviors. Important behavioral skills taught in Linehan’s method:
1. distress tolerance (desensitization, using the therapist to reduce anxiety)
2. emotion regulation (including affect identification and management)
3. interpersonal effectiveness (conflict resolution and empathy)
4. self-management (learning how to increase chances of success in meeting ones goals)
5. mindfulness (non-judgmental awareness)
These skills can be taught in individual sessions, but it’s more cost-effective to offer weekly didactic groups to teach basic skills while the individual therapy focuses on the problem areas most relevant to the particular patient.
Both Linehan and Young, in common with most therapists who work with trauma survivors, delay dealing with traumatic memories until the patient has sufficient trust in herself and in the therapist to withstand the high levels of emotional arousal that commonly accompany a focus on past trauma. It may require many months of preparation before a patient can reliably resist self-destructive impulses, maintain a stable lifestyle, and show significant progress in the basic skills addressed in Linehan’s Stage I.
Skillful treatment of PTSD is a complex, challenging, and contentious area. The basic goals are:
1. remembering and accepting the facts of earlier traumatic events, or learning to live with perpetual uncertainty about what actually happened; and
2. reducing stigmatization and self-blame
Arthur Freeman chairs the psychology department
At a recent symposium on BPD, Dr. Freeman gave some pointers on here-and-now focus in the treatment of PTSD. In his view, “The preferred intervention is the least intensive, least extensive, least intrusive, and least costly alternative that will provide what the patient requires at that time.”
Focusing on Cognitive treatment of intrusive recollections and flashbacks, Freeman suggests the therapist’s initial focus should be on assisting the patient to precisely characterize the experience so as to make it more concrete and less eerie for the patient. He asks for
1. A complete description of the thoughts or perceptions which constitute the episode;
2. Identification of anything in the current life situation which may have triggered the episode, with specificity as to the particular aspect of the current situation which was a trigger;
3. A description of emotions, thoughts, sensations, and behaviors which followed the episode.
Dr. Freeman’s approach shares with the majority of therapists working in this area the basic technique of converting emotions into words, which seems to assist the patient in gaining a sense of mastery over the strong emotions involved. He also encourages journaling for this purpose, and teaches relaxation and imagery as tools for self-soothing.
Traumatic nightmares are handled similarly to flashbacks; writing down the nightmare upon arousal is useful because some of the most important images will not be remembered the next day. Freeman emphasizes reinforcing the patient for gaining control over the intrusive recollections.
With reference to the specific problem of flashbacks which occur during sexual activity, Dr. Freeman suggests that sexual activity be interrupted until both partners are comfortable with its resumption; to close one’s eyes and wait for him to finish would tend to reinforce dissociation through reenactment of the trauma. Communication with the partner about what’s happening is encouraged, as is asking for the partner’s support. The patient can also train herself to pay attention to important differences between the current partner and the original perpetrator, including both differences in appearance and differences in the quality of the relationship. In some cases, the partner may need professional assistance to become more comfortable with the patient’s special needs; in others, the problem in need of attention may be the patient’s inappropriate choice of partner.
Linehan’s third stage puts appropriate focus on the patient learning how to maintain improvement without so much help from the therapist. Goals of this stage are:
1. non-defensive self-appraisal that will resist unreasonable attacks on one’s self-esteem; and,
2. trust in one’s ability to cope with stress.
In her discussion of telephone contacts between sessions, Linehan emphasizes the need to repair the relationship. Borderline patients often experience delayed emotional reactions to something the therapist said or did during a session. Often, the next call after a session relates in some way to such a delayed reaction. The therapists’s ability to accurately hear the underlying concern and to respond with empathy can substantially improve the chances for the patient to stay in therapy. Arthur Freeman suggests that each session end with an invitation for the patient to give the therapist some feedback, thus reducing the probability of rumination and after hours phone calls.
Linehan characterizes the skillful therapist as “able to balance a high degree of nurturing with benevolent demanding.” This is one of a number of paradoxical elements of the therapy situation to which she refers in her writing. Others are
a. Clients are free to choose their own behavior, but they cannot stay in therapy if they do not work at changing their behavior.
b. Clients are taught to achieve greater independence by becoming more skilled at asking for help from others.
c. Clients have a right to kill themselves, but if they ever convince the therapist that suicide is imminent they may be locked up
d. Clients are not responsible for being the way they are, but they are responsible for what they become
Such paradoxical elements can be presented to a patient at the appropriate time and in an appropriate manner, to stimulate reflection and to help the patient move beyond simplistic thinking. Linehan also recommends skillful use of metaphor, stories, parables, and myth in therapy. These techniques require a certain literary bent and much skill to apply; their strength is that they circumvent the patient’s logical resistance to new ways of thinking about the world.
Another advanced therapeutic technique recommended by Linehan, and applicable in any therapy, is to take the patient’s absurd position and logically extend it until even the patient sees the absurdity. This has to be done with exquisite sensitivity or the patient will feel mocked. Two examples cited by Linehan are:
1. The patient would rather die than gain weight; if being dead is preferable to being overweight, the overweight therapist is within reason to offer to join the patient in a suicide pact.
2. The patient will kill herself if the therapist won’t see her immediately; the therapist expresses great anxiety and offers to call an ambulance so the patient can be hospitalized for her own protection.
These are tricky techniques, in which the therapist both joins with the patient and proposes a therapeutic ordeal.
Linehan’s method, like Young’s, emphasizes the therapeutic relationship as the ultimate reinforcer of patient behavior. It is essential that the therapist pay a lot of attention to the patient’s progress and minimize attention to negative behaviors. The therapist may find herself in a dilemma when it comes to responding adequately to the patient’s self-destructive behaviors without reinforcing them. It may be helpful to frankly share this dilemma with the patient.
In her discussion of limit-setting, Linehan stresses that the therapist must understand the limits of his or her own tolerance for the patient’s bad behavior, and clearly communicate this information to the patient. “Therapists who do not do this will eventually burn out, terminate therapy, or otherwise harm the client.” She suggests the therapist be frank and unapologetic about some limits being for the good of the therapist.
Linehan chooses to instruct her patients that cognitive distortions are frequently a consequence of emotional arousal. This is a departure from a purely cognitive framework, in which dysfunctional cognitions are seen as the cause of turbulent emotion. None the less, Linehan shares with therapists all the way back to Sigmund Freud the basic idea that pausing for rational analysis is better than allowing one’s rawest emotions to govern one’s behavior. She also shares with most mainstream therapists a preference for techniques which encourage the patient to desensitize herself to the fear of emotion by repeatedly experiencing these emotions in the therapy sessions while the therapist assists her to delay any behavioral response.
In her discussion of therapist style, Linehan suggests that the therapist’s negative emotional reactions to the patient can be used to educate the patient about her impact on others. For example, “When you demand warmth from me, it pushes me away and makes it harder to be warm.” I’m a bit uncomfortable with this intervention because it contains embedded YOU statements: “you demand… you push me away….” A more authentic statement might be, “Sometimes I feel more distant from you at the very times when I sense you wanting me to show warmth to you. I wonder if others around you sometimes have the same response, and if there’s anything you could do differently to increase the chances of getting the response you want.”
Linehan also recommends the therapist try to stay in a consultant-to-the-client role, except when the patient is clearly overwhelmed. This helps to avoid infantilizing the patient, and also helps the therapist to avoid being sucked into confrontation with others over what’s “best” for the patient.
It’s important to remember that you can’t save every patient, especially the chronically suicidal ones, without locking them up for several years at a time. This means that if you don’t have the strength to bear the loss of an occasional patient to suicide, even the ones you really care about, you shouldn’t be in this business.
When you do lose one, it should be a learning opportunity. You as therapist should insist on case consultations from consultants chosen for their expertise rather than for friendship. This process is scary, but also uniquely growth promoting.
CONCLUDING REMARKS:
In summary, Borderline Personality Disorder is one of the most challenging entities for today’s therapist; in fact, this category originated as a repository for patients who fail to improve with ordinary treatment methods and whose particular pathology is most likely to provoke a negative emotional reaction in the therapist. Comfort and effectiveness in the treatment of BPD implies mastery both of one’s own emotions and of therapeutic techniques in general. It is not realistic to expect success in every case, and successful treatments are usually long and stormy.
Borderlines ARE treatable. Linehan’s study of 44 severely affected women, treated over one year with either Dialectical Behavior Therapy or “treatment as usual”, showed an attrition rate of only 17%, with reductions in frequency and severity of self-injury, and fewer hospital days for the patients treated with DBT. A second study showed improvements in anger management, social adjustment, work performance, and anxiety with DBT. These results were maintained at 6 and 12 month follow-ups. The original study was published in the Archives of General Psychiatry, vol 48(1991) pp 1060 ff.
The major open question is whether current restrictions on payment for psychotherapy will permit many borderlines to have effective treatment. No satisfactory brief therapy for BPD has been reported. In many settings, the best we can hope for is to deal with a series of crises in ways that may have a favorable cumulative impact on the patient. We must assist borderline patients to get their emotional needs met without their having to resort to grossly self-destructive behavior. The current tendency to provide acute medical treatment and outpatient referral rather than inpatient admission, and to keep inpatient stays very short, may actually be helpful in this regard, because it avoids reinforcing the patient’s dysfunctional behavior.
Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. identity disturbance: markedly and persistently unstable self-image or sense of self
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. 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)
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms
Borderline Personality Disorder
BPD is characterized by impulsivity & by instability in mood, self-image, & personal relationships. It is fairly common & is diagnosed more often in females than males.
Symptoms-
Individuals with BPD have several of the following symptoms:
+ 1. Marked mood swings with periods of intense depression, irritability &/or anxiety lasting a few hours to a few days.
+ 2. Inappropriate, intense, or uncontrolled anger.
+ 3. Impulsiveness in spending, sex, substance use, shoplifting, reckless driving, or binge eating.
+ 4. Recurring suicidal threats or self-injurious behavior.
+ 5. Unstable, intense personal relationships with extreme, black & white views of people & experiences, sometimes alternating between “all good” idealization & “all bad” devaluation.
+ 6. Marked persistent uncertainty about self-image, long term goals, friendships, values.
+ 7. Chronic boredom or feelings of emptiness.
+ 8. Frantic efforts to avoid abandonment, either real or imagined.
A person with a borderline personality disorder often experiences a repetitive pattern of disorganization and instability in self-image, mood, behavior and close personal relationships. This can cause significant distress or impairment in friendships and work. A person with this disorder can often be bright and intelligent, and appear warm, friendly and competent. They sometimes can maintain this appearance for a number of years until their defense structure crumbles, usually around a stressful situation like the breakup of a romantic relationship or the death of a parent.
Symptoms
Relationships with others are intense but stormy and unstable with marked shifts of feelings and difficulties in maintaining intimate, close connections. The person may manipulate others and often has difficulty with trusting others. There is also emotional instability with marked and frequent shifts to an empty lonely depression or to irritability and anxiety. There may be unpredictable and impulsive behavior which might include excessive spending, promiscuity, gambling, drug or alcohol abuse, shoplifting, overeating or physically self-damaging actions such as suicide gestures. The person may show inappropriate and intense anger or rage with temper tantrums, constant brooding and resentment, feelings of deprivation, and a loss of control or fear of loss of control over angry feelings. There are also identity disturbances with confusion and uncertainty about self-identity, sexuality, life goals and values, career choices, friendships. There is a deep-seated feeling that one is flawed, defective, damaged or bad in some way, with a tendency to go to extremes in thinking, feeling or behavior. Under extreme stress or in severe cases there can be brief psychotic episodes with loss of contact with reality or bizarre behavior or symptoms. Even in less severe instances, there is often significant disruption of relationships and work performance. The depression which accompanies this disorder can cause much suffering and can lead to serious suicide attempts.
Etiology
It is a common disorder with estimates running as high as 10-14% of the general population. The frequency in women is two to three times greater than men. This may be related to genetic or hormonal influences. An association between this disorder and severe cases of premenstrual tension has been postulated. Women commonly suffer from depression more often than men. The increased frequency of borderline disorders among women may also be a consequence of the greater incidence of incestuous experiences during their childhood. This is believed to occur ten times more often in women than in men, with estimates running to up to one-fourth of all women. This chronic or periodic victimization and sometimes brutalization can later result in impaired relationships and mistrust of men and excessive preoccupation with sexuality, sexual promiscuity, inhibitions, deep-seated depression and a seriously damaged self-image. There may be an innate predisposition to this disorder in some people. Because of this there may ensue subsequent failures in development in the relationship between mother and infant particularly during the separation and identity-forming phases of childhood.
Treatment
Treatment includes psychotherapy which allows the patient to talk about both present difficulties and past experiences in the presence of an empathetic, accepting and non-judgemental therapist. The therapy needs to be structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways. Sometimes medications such as antidepressants, lithium carbonate, or antipsychotic medication are useful for certain patients or during certain times in the treatment of individual patients. Treatment of any alcohol or drug abuse problems is often mandatory if the therapy is to be able to continue. Brief hospitalization may sometimes be necessary during acutely stressful episodes or if suicide or other self-destructive behavior threatens to erupt. Hospitalization may provide a a temporary removal from external stress. Outpatient treatment is usually difficult and long-term – sometimes over a number of years. The goals of treatment could include increased self-awareness with greater impulse control and increased stability of relationships. A positive result would be in one’s increased tolerance of anxiety. Therapy should help to alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality. With this increased awareness and capacity for self-observation and introspection, it is hoped the patient will be able to change the rigid patterns tragically set earlier in life and prevent the pattern from repeating itself in the next generational cycle.
Causes-
The causes of BPD are unclear, although psychological & biological factors may be involved. Originally thought to “border on” schizophrenia, BPD now appears to be more related to serious depressive illness. In some cases, neurological or attention deficit disorders play a role. Biological problems may cause mood instability & lack of impulse control, which in turn may contribute to troubled relationships. Difficulties in psychological development during childhood, perhaps associated with neglect, abuse, or inconsistent parenting, may create identity & personality problems. More research is needed to clarify the biolological &/or psychological factors causing BPD.
Treatments
-A combination of psychotherapy & medication appears to provide the best results for treatment of BPD. Medications can be useful in reducing anxiety, depression, & disruptive impulses. Relief of such symptoms may help the individual deal with harmful patterns of thinking & interacting that disrupt daily activities. However, medications do not correct ingrained character difficulties. Long-term outpatient psychotherapy & group therapy (if the individual is carefully matched to the group) can be helpful. Short-term hospitalization may be necessary during times of extreme stress, impulsive behavior, or substance abuse. While some individuals respond dramatically, more often treatment is difficult & long term. Symptoms of the disorders are not easily changed & often interfere with therapy. Periods of improvement may alternate with periods of worsening. Fortunately, over time, most individuals achieve a significant reduction in symptoms & improve functioning.
Co-existing Disorders-
Other disorders may also be present. Determining whether other psychiatric disorders may be involved is critical. BPD may be accompanied by serious depressive illness (including bipolar disorder), eating disorders, & alcohol or drug abuse. About 50% of people with BPD experience episodes of serious depression. At these times, the “usual” depression becomes more intense & steady, & sleep & appetite disturbances may occur or worsen. These symptoms, & the other disorders mentioned above, may require specific treatment. A neurological evaluation may be necessary for some individuals. Medications-Antidepressants, anticonvulsants, & short-term use of neuroleptics are common for BPD. Decisions about medication use should be made cooperatively between the individual & the therapist. Issues to be considered include the person’s willingness to take the medication as prescribed, & the possible benefits, risks, & side effects of the meds, particularly the risk of overdose. Dr. Allen Frances, Payne Whitney, 525 E. 68, NYC 10021, 472-5909
Drug treatments for Borderline Personality Disorder
By Carl Salzman, M.D. Professor of Psychiatry at Harvard Medical School
Borderline personality is a disorder with a variety of symptoms that can be briefly summarized as instability in mood, thinking, behavior, personal relations, and self-image. Borderline patients are moody, self-destructive, and sometimes subject to transient disorders of thinking. They suffer greatly and inflict much suffering on others. In its milder forms, borderline personality may be a type of mood disorder; the more severe forms may result from sexual and physical abuse. Often patients have never had a reliable emotional attachment to their parents.
Biological studies show inadequate regulation of serotonin, dopamine, and other neurotransmitters in patients with borderline personality. Monoamine oxidase (MAO) inhibitors, antidepressants that prevent the breakdown of norepinephrine and other neurotransmitters, have proved moderately helpful for borderline patients with rejection-sensitive dysphoria–excessive sensitivity to real or imaged rejection. But MAO inhibitors cause weight gain and sexual problems and can be lethal when taken in combination with stimulants or with foods containing the substance tyramine. Neuroleptics (antipsychotic drugs) in low doses are useful short term to reduce thinking disturbances, especially the tendency to misinterpret what others say and project hostility and rage onto others. The newer atypical neuroleptic drug clozapine may also help to control self-inflected injury and other abusive behavior in the most seriously disturbed patients.
A major breakthrough in the treatment of mild to moderate cases of borderline personality has been the introduction of selective serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Some have claimed that these drugs can actually change a patient’s personality. Although that is not likely to occur, SSRIs are useful in reducing anger, impulsiveness, and mood instability.
This therapeutic effect is due not only to their antidepressant activity but, more specifically to their enhancement of serotonin transmission. The serotonin system influences aggression and impulsive and self-destructive behavior. Enhanced serotonin function may improve the personal relationships of borderline patients by diminishing rage and mood changes and therefore producing a state of mild indifference to self-criticism and self-doubt. The therapeutic alliance is one of the relationships improved by SSRIs, and the resulting enhancement of the psychotherapeutic process is often striking. SSRIs are also used to treat obsessive-compulsive disorder, and there is evidence that they reduce obsessive ruminations in borderline patients. Yet to be seen is whether newer serotonin-enhancing antidepres-sants such as venlafaxine and nefa-zodone will be as effective.
SSRIs alone may be insufficient for some borderline patients, at least in the early stages of treatment. These patients may also need benzodiazepines for anxiety, restlessness, and sleeplessness. Care must be taken in prescribing these drugs, because borderline patients are more likely than others to overuse or misuse them. Borderline patients whose moods swing rapidly from depression or rage to elation may be helped by the addition of a mood stabilizer such as lithium, valproate, or carbamazepine. Very low doses of neuroleptics (anti-psychotic drugs) may reduce distortions of reality and communications. (Sept. 96, Harvard Mental Health Letter)