Borderline Personality Disorder
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Borderline Personality Disorder (BPD) might sound a somewhat less-serious problem or perhaps a disorder that resists being categorized. However, both are stereotypes having strong roots in the disorder’s history. Originally, the term “borderline” was used to describe a condition that was thought to “border” between neurotic and psychotic disorders. Its unusual and often confusing symptoms, combined with a lack of information at that time, led to an indistinct use of terminology, and consequently, misconceptions in definition. Since the DSM-III, it has been recognized as a unique type of personality disorder, and fairly recently, much concerning its etiology, course, and treatment has been identified.
Borderline individuals, sometimes referred to as “borderlines”, generally display a pattern of behavior marked by disruptions in identity, mood, and close personal relationships. First, their basic identity often has serious problems and is especially unstable. Likewise, it is standard to find their relationships are also quite erratic. In addition, the borderline may carry out desperate efforts to avoid real or imagined abandonment, become verbally abusive, threaten suicide, or have intense outbursts of anger with little provocation (Carson, Butcher & Mineka, 2000).
The borderline will often seek a relationship, not necessarily romantic, with someone who they believe cares about them and will be accessible. In addition to focusing on one person at a time, they tend to vacillate between modes of idealization and devaluation of the person, due in part to their unrealistic expectations for them. At any moment, if they believe that they are going to be abandoned, they frequently react with sheer panic. It is then that the prevalent destructive, angry, and manipulative behaviors surface in an effort to avert the anticipated loss of support (Gunerdon, Berkowitz et al., 1997).
Another characteristic of the borderline personality is impulsivity, which is often self-damaging. Because they are emotionally unstable, their behavior is often self-destructive and can include acts of self-mutilation, suicidal tendencies, alcohol or drug abuse, binge-eating, gambling, overactive sexual behavior, or reckless driving. It is suspected that self-mutilating behaviors are associated with relief from anxiety or dysphoria; research has also proposed that it may be associated with analgesia (not experiencing pain despite a theoretically painful stimulus). More often than not, suicide attempts have a manipulative purpose, though not always, for as many as 9 percent may indeed complete suicide (Carson, Butcher & Mineka, 2000).
The next aspect of borderline pathology is inappropriate, intense anger or difficulty controlling anger, such that extreme emotional and verbal outbursts with no apparent causation are common. The trademark instability of the borderline customarily reveals itself in this manner, creating an unpredictable and volcanic personality where emotional moderation is rare. In fact, a flat affect is so atypical that its presence is usually sufficient to rule out BPD.
One important feature of the borderline diagnosis is a vulnerability to brief psychotic episodes, which may include dissociation, hallucination, paranoid ideation, or lack of reality sense. Any of these can occur when the borderline’s environment lacks structure. For example, a borderline adolescent may perform well on structured tests such as the Wechsler inventories, but when presented with an unstructured test such as the Rorschach (which uses inkblots) they are apt to become extremely agitated. Stressors to the BPD individual can also produce psychotic-like effects (Fall & Craig, 1998).
We have all faced borderline personality disorder in our daily lives. The unfortunate truth is that it is seldom recognized or noticed much later than would be ideal. By then, BPD has depreciated the quality of the borderline’s life and dramatically affected the lives of family and friends. Actress Marilyn Monroe lived a vastly turbulent life, composed of failed marriages, numerous relationships, a history of substance abuse and suicide attempts, all of which suggest that she was “probably borderline” according to Dr. John W. Gunderson. Usually, borderlines ensure that someone “saves” them from their suicide attempts, but some take their lives, as Marilyn Monroe did at age 36 from a drug overdose.
Interestingly, commercial films have been used to educate people on various topics in psychology. It is important to note that some film depictions are clinically inaccurate and may in fact stigmatize the field of psychology. However, when used pragmatically, films can be utilized to enhance teaching as well as deliver useful information to the public.
A striking example of film based on the borderline’s fear of abandonment is made by the character Annie Wilkes (Kathy Bates) in the movie “Misery”. She is an obsessed devotee of a popular novelist named Paul Sheldon (James Caan), who coincidentally gets into a serious car accident near her home. After rescuing him from the overturned wreck, she brings him to her home and nurses him back to health. At first, Wilkes manages to keep most of her borderline pathology subdued; however, when Sheldon attempts to leave, she calmly restrains him and shatters his ankles with a sledgehammer to prevent him from ever leaving her. This extreme response clearly illustrates a borderline’s intense fear of abandonment and the extent to which they may go to avoid being abandoned (Hyler, 1997).
Since 1970, there has been tremendous growth in literature and the amount of research dedicated to borderline individuals. The concept of borderline psychopathology has shifted from that of a personality organization, characterized by symptoms of both psychotic and neurotic organizations, which made classification very difficult, to a syndrome with a set of criteria that help differentiate it. As a syndrome, it was initially considered an atypical of schizophrenia. Soon after, BPD was handled as an atypical form of several Axis I diagnostic categories, such as atypical depression, posttraumatic stress disorder, and bipolar II disorder. However, the concept of borderline psychopathology as a syndrome led to a third construct. With enough information known about its etiology and course, as well as specific treatments, BPD could then be separated from other personality disorders and stand alone as a disorder that is not mainly an atypical form of something else (Gunderson, Berkowitz, et al., 1997).
Causal and Contributory Factors
Current research is continuously bringing more knowledge of the inner-workings of the borderline’s mind. One psychoanalytic theory, called object-relations theory, is concerned with how an individual internalizes relationships with significant people, particularly parents. It suggests that the way you comprehend and absorb these relationships is intimately connected with other psychoanalytic notions, such as love and aggression, and strongly influences the development of the id, ego, and superego. Learning experiences are then divided into periods of low and high-intensity emotion; the child’s early learning during interaction with parents (the mother is specifically stressed) during emotional states of high-intensity sets precedence for their understanding of self-concept as well as how they perform in relationships with other people later in life.
A developmental model was suggested by J. Masterson, who worked within the four stages of [infant] development postulated by Mahler: autistic, symbiotic, separation-individuation, and object constancy. Masterson advocated that if problems in development, which he termed “developmental arrest”, occurs in the separation-individuation phase between the 18th and 36th months of age, conceivably due to the mother promoting and rewarding attachment but impeding autonomy, the child ultimately would interpret this message as “stay attached to the mother or die”. This may explain the borderline’s intense fear of abandonment and intolerance of being alone. Similarly, an adolescent who develops the arrest will continue to form relationships to escape abandonment, looking to create a bond of dependency. Without individuation, the person clearly lacks a sense of self and he/she will continue to think dichotomously, often called the “splitting” defense, by seeing others as “all good” or “all bad”, due to the lack of object constancy. This theory may sound outlandish, but consider the study performed by Bezirganian, Cohen, and Brook in 1993, which found that maternal inconsistency in child upbringing positively predicted the emergence of BPD but was not linked to any other personality disorder (Fall & Craig, 1998).
Childhood abuse is also a major contributory factor in the etiology of borderline personality. Environmental, familial dispositions such as physical and sexual abuse, severe deprivation of love, unavailable parental objects, and severe neglect, can all lead to the development of personality disorders (McGinn, 1998). These are such powerful influences that childhood abuse has become a diagnostic component. It only makes sense that children who are abused form a distorted sense of reality filled with feelings of fear, anxiety, and unpredictability. Overall, the etiology of BPD seems to be a complex exchange of chaotic forces present within the child’s environment (Fall & Craig, 1998).
Once BPD is considered a disorder of conflict, a number of deficits can be identified using current knowledge about its definition, etiology, and treatment. Three deficits are recognized in borderline individuals–“affect and impulse control”, “dichotomous thinking”, and “intolerance of aloneness”; counseling patients and families about them create the setting for the psychoeducational form of treatment, and by suggesting these are “handicaps that are not disabilities”, the “recovery is possible” perspective is maintained. It is thought that although the disorder poses severe limitations, these limitations can be overcome through long-term treatment or rehabilitation.
The first step in psychoeducational treatment is obtaining a profile of what the borderline and their parents see as the major problems burdening them. Following this, because families enter the mental health arena with defensiveness and fear of blame, the initial approach to counseling parents begins with offering the idea that they have a direly troubled offspring. It is sympathetic, and questions about development and expressing feeling are not presented, but parents are not exempted from any responsibility. Thought to be a proactive and future-oriented approach, this moves parents away from issues surrounding their possible causal role, which is considered counterproductive to dealing with the present situation; skills geared toward coping with the borderline’s blaming are emphasized.
“Joining” is done by conducting up to four meetings with individual families, one at a time. A history of the problems encountered is gathered, and several relatives are brought into a workshop in which educational material is delivered with the goal to make everyone more challenge-solution oriented and less crisis oriented. The other half of therapy involves “Multiple Family Group” sessions, in which families share the problems they face and relate to each other. The question of whether the borderline individual should be included in these meetings is still open, although most parents object to it citing the meetings as form of refuge. Overall, this form of therapy is designed to create a healthy, “designer” environment for the borderline, for which the goal is to trigger extreme emotional responses less frequently; it does not specifically address BPD psychopathology (Gunderson, Berkowitz et al., 1997).
Dialectical Behaviour Therapy (DBT), developed by Linehan, is a “structured, time-limited, cognitive-behaviourial treatment originally developed for Borderline Personality Disorder clients who have chronic parasuicidal problems”. In addition, it may be helpful to state that the term dialectic is defined as “The art or practice of arriving at the truth by the exchange of logical arguments”.
Linehan identified five main treatment tasks founded on her capability deficit/motivational model of the development of the disorder. The treatment must enhance the capabilities of the borderline, motivate them to use these capabilities, generalize the use of the capabilities to all applicable contexts, aid the client in structuring their environment to promote progress in other contexts, and lastly due to the tendency of the borderline to discredit and resist therapy, address the capabilities and motivation of the therapist. The therapist conveys skills training, which encompasses core mindfulness, distress tolerance, focusing on acceptance and emotional modulation, and interpersonal effectiveness–all of which were adapted from Zen Buddhism. Also, by focusing on tasks rather than modalities, therapy can be adapted to a variety of environmental settings.
To achieve these tasks, DBT organizes the individual’s presenting problems into five stages of treatment, each representing a substantial decrement in the degree of pathology. In the pretreatment stage, the therapist seeks to gain a commitment to the goals of treatment from the borderline, and if at any point in therapy this commitment wavers, the therapist returns to this stage. Stage I, the most distinctive and rigidly structured, is aimed at the client’s attainment of basic behavioral abilities. Stage II focuses on reducing posttraumatic stress, and unlike other treatments, is begun later due to the belief that the client should have adequate coping skills to handle the emotional intensity of this effort. Similar to pre-treatment, if the person begins to elicit behavior typical of an earlier stage of treatment, the therapist moves back to that stage. The goals of Stage III are to increase self-respect and start achieving individual goals. In this way, the borderline learns to trust themselves, validate their own thoughts, opinions, and emotions, as well as to respect themselves independently of a therapist. Stage IV, the last stage, focuses on overcoming problems of daily life. Ironically, many of us are trying to accomplish some of the goals set in Stages III and IV ourselves (Swales, Heard & Williams, 2000).
Many other forms of treatment for BPD are available. Hospital treatment is used when the problem is severe and the borderline would be unresponsive to outpatient forms of treatment or if the borderline person is dangerously suicidal. Case management is another option, where a case manager is assigned to a family needing assistance. The case manager helps the family manage the the impact of borderline behavior in their daily lives. From the client perspective, the partnership with a case manager is thought to give a sense of personal confidence, and hence, decreases the family’s perceived need for the service (Nehls, 2000).
To say Borderline Personality Disorder is complex is an understatement of immense proportion. Where twin studies have shown minimal genetic influence in its emergence, psychoanalytic approaches seem to be the plausible answer. It has been said that people are a product of their environment, and while this may seem to oversimplify the problem, it is rational considering BPD is five times more common in first-degree relatives than in the general population. What remains complex and nearly incalculable is the range of variables that are in play during the child’s development. Even so, we are fortunate to have substantial information available about the disorder and various ways to treat it (Fall & Craig, 1998).
In contemplating the forms of treatment, each has its own substantial shortcomings. Psychoeducational treatment is targeted mainly to the family of the borderline individual. It may create an environment that activates the borderline’s sensitivities less, but does not account for the therapeutic or lifetime need of the borderline to foster independence when approaching adulthood. It may also serve to hamper the borderline’s recovery from posttraumatic stress if a form of abuse had taken place, by shifting focus away from the parents’ accountability. At a glance, DBT appears to be a more rigorous, in-depth recovery plan whose benefits directly affect the borderline, but misses the role of the family and the trials they encounter during the person’s long-term recovery. Surely, the best form of treatment will be eclectic and will benefit the family and the borderline individual equally.
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