Borderline Personality Disorder

Revised and with a new afterword by the author

by John M Rathbun M.D.

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 are common

* Genetic data implicate constitutional factors

DIAGNOSIS:

* They typically present with dependent behaviors, seeking nurturance, closeness, and assistance

* Within a therapeutic relationship, they show escalating need for support

* When frustrated, they show rage and devaluation of therapist

* Their relationships are typically unstable, intense, and stormy

* They show extremes of idealization and devaluation

* They may become extremely ill and self-destructive in reaction to fear of abandonment

* They commonly have other personality disorders, mood disorders, substance dependence, bulimia, and PTSD

DIFFERENTIAL:

* Compared to cyclothymic and bipolar patients, BPD are more reactive, angry in reaction to frustration in dependent relationships, with chronic feelings of emptiness

* Compared to depressive disorders, BPD are 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 is especially severe around age twenty-five

* About half improve spontaneously in their 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:

* Selective serotonin reuptake inhibitors and mood stabilizers help impulse control and moodiness

* Antipsychotics help ideas of reference and brief psychotic symptoms

* Benzodiazepines and mood-altering chemicals 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.

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.

MH Today	MH Bookstore	Attention Deficit	Bipolar	Borderline Personality	Borderline Bookstore	Depression
Gender Identity	Narcissistic Personality	PTSD	Schizophrenia	Seniors	Suicide	Mental Health Exercises

Visit MH Matters for information and articles. Get help to find a therapist or list your practice; and Psych Forums for message boards on a variety of MH topics.

Sponsors: Aphrodite's Love Poetry ¦ Make Money on the Internet

Amazon Related Books

BPD Today Bookstore