Borderline Personality Disorder
What is "borderline personality disorder"?
If I could use one word to describe boarderline personality disorder, it would be the word unstable. These patients have unstable sense of self, unstable relationship, unstable moods, they are very impulsive. I think another characteristic commonly seen in these patients are that they would do almost anything avoid feeling abandoned. The abandonment doesn't have to be real, it can be imagined. The hallmark of the disorder, or what people most frequently know about it, they tend to be quite self-destructive, and self-mutilation is relatively common.
What are the signs of borderline personality disorder?
Since these patients will make frantic efforts to avoid a sense of feeling abandoned, you know, they will be very needy and dependent. Now, as I say that, while they're very needy, and don't want to feel abandoned, it should be mentioned that that dependency on others while they feel it's absolutely necessary to their continued existence, they also find it rather terrifying and intimidating. So, the clinical presentation of a patient with borderline personality disorder is very variable. It's incredibly variable between patients, it's incredibly variable within a single patient depending on what time of day you catch them and what kind of mood they're in. However, I would tell you that invariably, most of them will report a chronic dysphoria: an unhappiness. They often have feelings of emptiness, their relationships with other people tend to be very stormy and ungratifying, they often will fluctuate between totally idealizing you and completely devaluing you. So one moment you're like the most wonderful guy they've ever met in their entire lives, and the next second, you know, if you disappoint them or do something to upset them, they hate your guts and never want to see you again. Which can explain some of the interpersonal dysfunction in these people. As I mentioned before, one of the more dramatic hallmarks of the disorder for which a lot of people know them for is the self-mutilation. Now this is distinctively different than suicide attempts, although these patients will make suicide attempts. However the self-mutilation is described as in a whole different vein. What patients often describe as a rising tension that they're unable to tolerate, and one of the ways they get rid of that tension is if they cut on themselves. So you'll see what people often refer to as 'hesitation marks,' but it's like superficial cuts, you know, all over. And once they feel the pain or see the blood, they'll describe as the release of tension. I'm pointing to my arms here but you know, often patients will make the cuts on their legs where some of it can't be readily seen.
What are the causes of borderline personality disorder?
I think there's two schools of thought. There's definitely a group of people who feel that borderline personality disorder has some biological basis to it or genetic component. It is more common in people with first degree relatives that have borderline. Again, I don't think that this is necessarily means that a genetic component. Probably one of the best ways to become a broderline is to get raised by one. So that family, a higher family incidence might represent a learned behavior. There's also another school of thought that this is developmental. In other words, there's a lot of literature devoted to examining the developmental deficiencies in parenting that patients with borderline personality received or, actually, failed to receive. It is interesting to note that a large number of these patients have childhood histories of sexual abuse, physical abuse and or neglect. The degree to which that is causative in terms of the personality disorder is unknown at this time.
What are the dangers of borderline personality disorder?
I think first and foremost, these patients are prone to making suicide attempts or suicide gestures, and these patients know you could really kill yourself accidently even though that may not have actually been your intention. I've also seen them hurt themselves incredibly badly in a suicide attempt that they've misjudged. One girl, for example jumped out of a second storey window and was paralized from the neck down for the rest of her life afterwards, and that clearly wasn't her intent. I think she had hoped that she would be injured in a rather dramatic fashion but she got a lot more than she bargained for. In a less serious manner though, I think the other dangers involve chaotic, stormy, ungratifying interpersonal relationships with other people. Mostly based on these patients fluctuating moods and presentation as well as their tendency to become incredibly angry. It's difficult for them to have relationships that are meaningful or that last to any degree. They are prone to depression and anxiety disorders as well. There are a lot of what we call co-morbid diagnosis seen in people with borderline personality disorder. Co-morbid refers to other diagnosis for which they meet criteria for. So, it's quite common for these patients to get diagnosed with a variety of mood disorders, anxiety disorders, as well as eating disorders and substance abuse is also very common in these patients.
Who is at risk for borderline personality disorder?
It hasn't been exactly worked out in terms of actually being causative, but it's very common for these patients to have histories of physical abuse, sexual abuse, and/or neglect. It would appear that that may represent a risk factor. It is also more common in the first degree relatives of patients with borderline personality disorder, which might represent a genetic component or perhaps even a learned response.
What are the treatments for borderline personality disorder?
There have been books and books and books written about the psychotherapy of borderline personality disorder and how you should do it, and everybody has lots of different ideas about how it can be accomplished. I think in general, though, it's trying to develop some insight in these patients that their behaviour is actually responsible for people's reactions to them and the chaos in their lives. Treatment, the individual psychotherapy with a borderline patient, can be very challenging because they will try to recreate the chaos in their external lives and the internal chaos they feel; they'll try to recreate that in the psychotherapy setting. So, if you have a borderline patient in psychotherapy, hold on tight because it's going to be kind of a ride. You've got to be able to tolerate the ups and downs. Oftentimes it appears that the patient is trying to go from crisis to crisis to prevent any meaningful work getting done in therapy, and a lot of what you end up doing is managing those crises. What we end up doing is treating a lot of the symptoms; lots of mood stabilisers and anti-compulsants have been used to address the impulsivity seen in these patients, or even the rage attacks that they're prone to. Since many borderline patients meet the criteria for mood and anxiety disorders it is very common for them to get treated for that as well. Then, they are prone to transient psychoses when they get stressed out, and so it's not uncommon to see them on low-dose antipsychotics.