What is Borderline Personality Disorder (BPD)?
The term ‘borderline personality disorder’ was first coined by psychiatrist Adolph Stern in 1938. ‘Borderline’ refers to Dr Sterns’ belief that patients showed both neurotic as well as psychotic features. Neurosis refers to emotional or mental instability. Psychosis on the other hand is specified as severe instability involving break with reality, typically accompanied by hallucinations, delusions or other thought disturbances.
Research results differ as to potential gender difference: although some studies indicate no significant gender difference, others found 70-80% of those diagnosed with BPD to be female. The latter finding may be influenced by the fact that women with BPD tend to seek help more in clinical settings where most research is conducted, whereas men with BPD are more known to seek help in alcohol or drug treatment centres that are in part private. Research findings indicate that BPD patients make up approximately 20% of the psychiatric inpatient population in the US, and given the costs to the health care system, BPD is well researched and treatment has become more available.
Symptoms of Borderline Personality Disorder
It is important to remember that personality difficulties exist on a continuum, ranging from useful ways of being in the world on one end of the continuum, to maladaptive or unhelpful ways of being in the world on the other end of the continuum. When distressed, most of us move towards the unhelpful end of the spectrum, thus end up displaying behaviours that we are in hindsight not too proud of, and perhaps even ashamed of. The latter is a common experience for individuals diagnosed with Borderline Personality Disorder. In general, common set of difficulties observed in BPD sufferers include:
What is it Like to Live with BPD?
To understand the day to day experience and difficulties experienced by those living with BPD, it is perhaps necessary to look at the complex causal factors contributing to the development of BPD. According to Marsha Linehan, founder of one of the few evidence supported treatment approaches for individuals suffering from BPD, suggests a biopsychosocial model in understanding BPD. That is, patients may have a biological vulnerability to affect dysregulation, and this may be reinforced by an invalidating environment during early formative years.
Affect dysregulation translates into experiencing strong emotions coupled with difficulties in managing and expressing these emotions in ways that are beneficial to the individuals and those around them. Emotions tend to be experienced as confusing and overwhelming, and BPD clients report frequently scanning their environment for signs of how they should feel or act, followed by a display of feelings or behaviours they believe others expect from them.
Invalidation occurs when parents or other caregivers intentionally or inadvertently only respond to children when they are escalating, for example by throwing a temper tantrum. In doing so, they reinforce such dramatic display of emotions as a way of getting attention and needs fulfilled. This experience of invalidation may very well lie at the heart of BPD sufferers to react rather viciously to perceived invalidation or rejection later in life.
Is BPD Genetic?
Twin and family history studies have shown a genetic influence in that there are higher rates of BPD and other related mental health disorders among close family members. Some studies indicate a high number of BPD sufferers to be survivors of early and severe childhood abuse. This, however, is only part of the puzzle given diverging findings showing BPD patients with positive childhood experiences, as well as childhood abuse survivors not developing BPD.
Borderline Personality Disorder and Childhood Trauma
Gabor Mate, well known addictions specialist in Vancouver’s Downtown Eastside, believes mental health and substance abuse are both due to attachment disruptions or early childhood trauma. In this context, attachment refers to the emotional nurturing bond between caregiver and child.
Neurobiological research has shown that substance use in some people can serve as a substitute for unmet attachment needs, and substances then work to replace absent self-soothing and emotion regulation skills that individuals with attachment wounds typically lack. This is a particularly interesting hypothesis as to the causes of BPD, considering the significant co-occurrence between BPD and substance abuse in general, and opiate prescription abuse in female BPD sufferers in particular. Opiates are known to not only reduce physical pain, they are also emotionally soothing.
Attachment disruptions would also explain the quick emotional escalation observed by individuals with BPD when they believe they are rejected or possibly abandoned, and their tendency to seek constant reassurance. Also, these behaviours are well-documented adult attachment patterns for individuals with an anxious style of attachment. This, in turn, is a potential outcome if a person grows up with the inconsistent, neglectful or invalidating parent-child interactions so commonly encountered in the history of clients with BPD.
Borderline Personality Disorder and Interpersonal Relationships
The aforementioned symptoms experienced by BPD sufferers often result into significant and enduring impairment in interpersonal relationships, and overall day-to-day functioning. Borderline Personality Disordered patients frequently report a string of short-lived and often intensive relationships and jobs, often infused by repeated crisis of some sort. This instability augments already existing self-hatred, and self-harm in the form of cutting, burning or hitting oneself as well as suicidal gestures are common ways of dealing with lifelong failure to create what they long most for: stability, security in relationships and identity. Unfortunately, it is exactly this longing for security and stability – particularly as it pertains to relationships – that makes for crisis and instability.
Borderline Personality disordered clients are terrified of being abandoned, and hypersensitive to perceived rejection. This ever-present fear and hypervigilance is coupled with problems controlling explosive anger, as well as a strong tendency to emotion driven impulsive behaviours. Together, these features make for a rather volatile combination, and others around them often feel they walk on eggshells as they cannot understand or predict this intensive, quick-changing emotionality, which often involves threats of self-harm or suicide.
Borderline Personality Disorder and Self-Injurious Behaviours
Self-injurious behaviours are very common in BPD sufferers, often reflecting an attempt to soothe, regulate, numb or distract from the overwhelming emotional distress these individuals experience. Unfortunately, this is often mistaken as attention seeking behaviour, and this misinterpretation can result into actual interpersonal rejection so feared by individuals BPD. Due to the latter, individuals with borderline personality disorders tend to be well known to police, mental health teams and hospital emergency departments. Brief hospitalizations are unfortunately frequent, yet remain unhelpful as they reinforce the crisis driven approach to life BPD patients already live, and reinforce their core beliefs that they are unable to help themselves.
Women with BPD are perhaps even more prone to experiencing this painful vicious cycle, given that women tend to be more invested in relationships then men and thus more likely to be devastated when things go wrong interpersonally. Women with BPD may also be more negatively impacted in other ways: Mothers with BPD may be particularly prone to involuntary contact with child welfare authorities and become subject to mandatory intervention. Unfortunately, the above mentioned instability, coupled with repeated hospitalizations as a result of (threats of) self- harm or suicide may translate into great difficulties providing a stable, safe and predictable environment for their children.
Concurrent Disorders Involving BPD
Not surprisingly, patients with this diagnosis also often experience severe levels of clinical depression rooted in a deep sense of shame. Borderline Personality patients also show a strong overlap with other mental health problems and they are the ones most likely to develop substance abuse problems. In addition to depression, research has shown that about 88% of BPD patients also suffer from an anxiety disorder, most notably panic disorder (experienced by approximately 40% of BPD clients), and PTSD (observed in about 47-56% of BPD sufferers). BPD also often co-occurs with eating disorders (7-26%) and 50-65% of all BPD clients develop substance abuse problems over a lifetime. Conversely, 16-22% of all alcohol and drug treatment seekers are those with BPD, and one study found 46.9 % in patients abusing psychiatric medications to be BPD patients. Patients with BPD also show earlier onset of alcohol, drug or prescription medication misuse and they develop more severe levels of use.
While male BPD patients are more prone to develop severe polysubstance abuse involving illegal substances, female BPD sufferers appear to be particularly prone to the misuse or abuse of prescription medications such as opiates or benzodiazepines. Research also shows that females with BPD are overrepresented in substance related suicides, but underrepresented in clinical alcohol and drug treatment centres that address such complex problems. Impulsivity and the inability to regulate or endure difficult emotions are commonly observed in both substance users and individuals diagnosed with BPD. Unfortunately, the co-occurrence of BPD with substance abuse worsens the treatment course and outcome significantly and BPD was in fact shown as the only mental health diagnosis showing consistently negative outcomes: Unplanned or early discharges from alcohol and drug treatment facilities are common, as is relapse after treatment completion. Co-occurrence also makes for more problems and higher instability regarding employment, housing, education and interpersonal functioning.
BPD is a Complex Condition
Given the complexity of the condition, many clinicians working with BPD patients believe BPD is a misnomer. They suggest instead that a diagnosis of complex PTSD reflects more accurately the complex symptomatology and chronic difficulties experienced by individuals with a BPD diagnosis. Whatever the most accurate diagnostic term may be, there is little doubt or debate about BPD sufferers requiring specialized and long-term treatment. This is particularly evident in light of the co-occurrence with other mental health and substance abuse problems.
Dialectical Behaviour Therapy for BPD
To date, Dialectical Behaviour Therapy (DBT) remains the most evidence supported treatment for patients with BPD. DBT balances acceptance and change based strategies, and involves learning of behavioural skills in the areas of mindfulness, emotional regulation, distress tolerance and interpersonal relationships. DBT therapy typically involves behaviour skills groups as well as individual coaching sessions. The latter focuses on addressing identified maladaptive or ‘target’ behaviours, such as self-harm or interpersonal outbursts. Individual sessions also focus on helping clients individually to implement the skills they learn in group sessions into their day to day lives. DBT sessions tend to be rather didactic and highly structured, and participants are expected to complete weekly diary cards as well as worksheets in between sessions. This, together with the fact that DBT therapy is typically long-term and can be expensive if accessed privately, renders DBT not necessarily suitable or accessible for every BPD sufferer.
As a potential alternative to DBT, mentalization-based treatment, Systems Training for Emotional Predictability (STEPPS) are two other forms of therapy that have recently been supported by clinical trials. STEPPS is a modified version of DBT, also focusing on the acquisition of emotion and behaviour management skills over a 20 week period with weekly sessions. Very different from these therapeutic modalities, Mentalization-based treatment (MBT) is informed by attachment theory and focuses on enhancing patients’ ability to understand their own as well as others’ mental and emotional experiences. It is believed that the capacity to mentalize is at the core of emotional regulation and interpersonal functioning, which forms the basis of prosocial and effective behaviour. MBT also involves group and individual therapy over the course of 18 months, with strong emphasis on the therapeutic relationship between therapist and client.
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