This session focuses on Borderline Personality Disorder (BPD).
Borderline Personality Disorder (BPD) is a combination of disruptive behavioral problems, mood and anxiety symptoms, and cognitive symptoms. Some researchers use the term Borderline to describe this clinical picture because of the resemblance to BPD in adults, but others propose that the term Multiple Complex Developmental Disorder be used.
Borderline Personality Disorder (BPD) is characterized primarily by:
· Extreme "black and white" thinking (i.e., believing that something is one of only two possible things, and ignoring any possible "in-betweens")
· Turbulent relationships
· Instability in mood, interpersonal relationships, self-image, identity, and behavior
· This instability often disrupts family and work-life, long-term planning, and the individual's sense of self
· The majority of those diagnosed with this disorder appear to have been individuals abused or traumatized during childhood
When a child with a genetic propensity toward BPD is raised in a stressful environment (i.e., seriously dysfunctional family, emotional neglect from parents, exposure to sexual and/or physical abuse), BPD often manifests itself. BPD involves a chemical imbalance in the brain, but will worsen or be triggered in a hostile environment.
Borderline Personality Disorder is an illness of young people, and usually begins in adolescence or youth. Symptoms of BPD are usually present by late adolescence. The initial diagnosis of this disorder is rarely made in patients older than 40 years.
BPD can be diagnosed later in life, but does not emerge later in life. BPD typically starts sometime before the mid 20's. BPD might come to clinical attention later in life, but most individuals had some of their BPD symptoms as teenagers.
Like any other medical illness, BPD can evolve with time. Symptoms might worsen over time or even change (e.g., cutting as a teenager might give way to depression or migraines or hyper-sexuality as an adult).
BPD is biological in origin (e.g., like bipolar disorder). BPD can present differently with age. We all change how we act somewhat as we age. Our core personality or manner of interacting, however, does not change very much. By definition, BPD tends to be a lifelong behavior/collection of traits. BPD can wax and wane with intensity, but it is always present as a mode of interacting with others.
Virtually every study of BPD has revealed that the diagnosis is more common in females than in males (female-to-male ratios are as high as 4:1).
It is normal to feel vulnerable, so most people have experienced some of the symptoms on this list. The diagnosis of borderline personality disorder is made only when someone has had many of these symptoms to a severe degree, over a long period.
Unstable, intense and difficult relationships
Self-destructive, impulsive behavior
Suicidal threats or attempts
Extreme mood reactions, including intense, inappropriate anger
Feeling empty or alone
Fear of abandonment
Short-lived psychotic-like distortions of perception or belief, especially under stress
Some behavioral symptoms include:
rapid increase in dissociation and black-white thinking
undertones of "I don't want to deal with this"
aggressivity in everyday interactions between mother and children (although, if you just look at the surface, the mother is doing almost "perfectly" most of what she is supposed to do as mother)
screaming rages "I hate you …I hate you ..." (although child sometimes searches out mom for physical proximity)
very conflicting messages from mother to child (e.g. mother responds to the "I hate you" statement by kissing the child and saying, "Now you can't hate me because I kissed you")
Individuals with BPD show a wide range of impulsive behaviors, particularly those that are self- destructive. Borderline patients present to psychiatrists with repetitive suicidal attempts. These patients are often seen in the emergency room, coming in with an overdose or a slashed wrist following a disappointment or a quarrel.
Typically, borderline patients have serious problems with boundaries. They become quickly involved with people, and quickly disappointed with them. They make great demands on other people, and easily become frightened of being abandoned by them. Their emotional life is a kind of roller-coaster.
There is no specific or universal method of treatment for BPD. At times, drugs can take the edge off impulsive symptoms (e.g., low dose neuroleptics). However, no psychopharmacological agent has any specific effect on the underlying borderline pathology. In spite of the association between impulsivity and low serotonin activity, specific serotonin reuptake inhibitors (such as fluoxetine) rarely produce a dramatic improvement.
The mainstay of treatment for BPD has always been, and continues to be psychotherapy. However, because of their impulsivity, about two thirds of borderline patients drop out of treatment within a few months. Those patients who stay in therapy will usually improve slowly over time.
A patient with BPD may be continuously suicidal for months or years. Moreover, many of the same problems that patients have with other people arise in their relationships with helping professionals. Most of the work in psychotherapy consists of helping patients to be less impulsive, and to exercise better judgment in their management of their personal lives.
The problems in this disorder are related to the person's habitual ways of relating to others and coping with obstacles. People with this disorder tend either to idealize the therapist or to become frustrated easily. They have exaggerated reactions to disappointment. Therefore, it may be difficult for them to sustain a relationship with a mental health professional. This disorder tests the skill of therapists, who have to use a combination of techniques to be effective.
It's not enough for a person with this disorder to learn coping strategies on an intellectual level. The person has to learn how to tolerate the emotional discomfort that is common in relationships and to manage their intense emotions more successfully.
A form of treatment called dialectical behavior therapy (DBT) tries to take the special problems of borderline personality disorder into account, using a combination of psychotherapy techniques, education, and both individual and group psychotherapy to support the patient's progress.
At first, treatment aims at helping the person endure feeling isolated, depressed or anxious without resorting to self-destructive behavior. To accomplish this, hospitalization sometimes is necessary.
Outside the hospital, a person with borderline personality disorder may need additional support, such as day-treatment programs, residential treatment, or group, couples or family therapy.
As with psychotherapy, there is no single medication that is clearly helpful in borderline personality disorder. Instead, medication is usually used to treat symptoms as they emerge.
Antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs) can be used for depression and anxiety. There is also some evidence that this group of drugs reduce anger. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa).
Sometimes, a mood stabilizer is added or used by itself. These include lithium (Lithobid and other brand names), divalproex sodium (Depakote) or topiramate (Topamax). Antipsychotic medication, such as risperidone (Risperdal) or olanzapine (Zyprexa), may be tried if the person's thinking is distorted.
People with borderline personality disorder are more likely than average to commit suicide. They should discuss self-destructive impulses with their health care professionals and make specific plans for what to do to get help when these thoughts or impulses arise.
Mark Hutten answers the question: What is the difference between Oppositional Defiant Disorder and a Personality Disorder?