T3 - Borderline Personality Disorder

I would be remiss not to discuss Borderline Personality Disorder (BPD), even though I discussed it briefly here months ago for someone's character assessment.

Borderline falls into Cluster B personality disorders and keeps company with Histrionic, Antisocial, and Narcissistic PDs, all of which are marked by drama, emotion, and erratic behavior.

Borderlines, as individuals with this disorder can be called by those in the industry, have historically been considered to be on the border between psychosis and neurosis. Psychosis is a loss of contact with reality. (Literally, from the Greek words "psyche" for mind and "-osis" for abnormal condition--an abnormal condition of the mind.) These people experience an alter reality where hallucinations and delusions and bizarre behavior are common-place. Neurosis has become sort of a pop-psychology term to describe a way of existing that's distressful, but not outside societal norms. (For example, someone with a phobia or with obsessive-compulsive disorder or anxiety would be considered neurotic, but not actively psychotic.)

If that gives you any indication how life is for a Borderline, then you should understand this is no walk in the park. The essential feature of BPD is a pervasive pattern of instability in personal relationships, self-image, and affects, and marked impulsivity that begins in early adulthood and is present in a variety of contexts. There are 9 diagnostic criteria, of which a person has to have 5 or more of the following:

1) Makes frantic efforts to avoid real of imagined abandonment. Borderlines are sensitive to environmental circumstances, and nothing escapes their attention. Even if the separation is time-limited (just a week) or unavoidable (workshop for work calls you to travel away or you're late meeting them because there was a traffic accident), they will experience intense fear of abandonment and inappropriate anger.

2) Has a pattern of unstable and intense relationships. They put friends/lovers on pedestals and idealize them, wanting to spend as much time together as possible and giving too much out too much intimate information in relation to how long they have known them. However, they can quickly switch to devaluing them, feeling the other person isn't there for them enough or doesn't care or give enough.

3) Identity disturbance characterized by markedly and persistently unstable self-image or sense of self. Goals, values, aspirations, career plans--anything and everything is up for change. They might put come off as needy one day and then seeking revenge the next with a strong personality. People who know them really feel that they don't know them.

4) Display impulsivity in at least two areas that are potentially self-damaging. There are a number of areas that can meet this requirement, such as; gambling, spending money irresponsibly, binge eating, abusing substances, practicing unsafe sex, driving recklessly.

5) Recurrent suicidal behavior, gestures, or threats; self-mutilating behaviors. This is often the reason for Borderlines to seek help in the first place and is considered a hallmark trait. The completed suicide rate is high amongst this population (usually 8-10%). Self-mutilation, which includes cutting or burning, are very common. (Cutters usually favor the inside of the forearm or the tops of the thighs, but wounds can exist anywhere.) These acts are usually caused by a threat of separation/rejection or expectations from their partner that the Borderline assume more responsibility in the relationship. Cutting and burning (can be with flame or even pencil erasers rubbed extremely fast over the skin) may happen when the person is dissociative (not fully themselves) and often brings about a relief for the individual because the pain is preferable to the emotion. (I've had a few clients say that they feel so numb, and that cutting allows them to feel something, which is reassuring. Others say cutting themselves is a way for atoning for their being an evil/bad person.)

6) Affective instability due to a marked reactivity of mood. Borderlines have one basic mood: dysphoria. When a person feels dysphoric, they feel a state of unease and generalized dissatisfaction of life. But a Borderline's dysphoria can be disrupted by periods of intense anger, panic or despair that can last a few hours...rarely more than a few days.

7) Chronic feelings of emptiness. They may be easily bored and so therefore constantly seeking something to do.

8) Express inappropriate, intense anger or have difficulty controlling their anger. This could manifest as extreme sarcasm, verbal outbursts, or physical fights. The anger results from when the Borderline feels than someone is neglectful, witholding, uncaring, or abandoning. After expressing themselves, they often feel guilt and shame while furthering their opinion that they are evil.

9) Brief periods of paranoid ideation or dissociative symptoms may occur during times of extreme stress (but generally not enough to warrant another diagnosis). By brief, I mean minutes to hours. Usually, this is also as a result to real or imagined abandonment. They may feel that they are briefly outside their body, a condition called depersonalization.

The thing to remember about Borderlines is that they can lie and manipulate extremely well. Unlike Antisocials, who use power to get what they want, Borderlines appear to use their weaknesses to manipulate. Dr. C. George Boeree commented on his website, "They pull you towards them, then push you away, then pull you back. They pit one friend against another. They dramatize situations to their own ends. They move, chameleon-like, from one "personality" to another." This description reminded me of a book I had to read in school. The title, I Hate You--don't leave me, is indicative of the nature of a Borderline.

Borderlines are hard to treat. Very hard. Therapists are not immune from the idealization/devaluation that Borderlines do, and this makes for talk therapy difficulties. When I slipped from the pedestal for one Borderline client, regaining ground was hard. She thought I was uncaring, but in reality, it was only because I cared that I told her what I had noticed about the patterns in her behavior, trying to help her be self-aware. They also have a typical pattern of regressing just as therapy is going well, to avoid the perceived abandonment of terminating therapy. So you can see the inherent difficulties in just being friends with someone like this, much less treating them.

As for what type of childhood these individuals had, some common backgrounds from Borderlines across the country are physical and sexual abuse, neglect, hostile conflict and early parental loss or separation. Medications and therapy (and patience) are the best modes of treatment. Borderlines can be found in about 2% of the general population, 10% in outpatient mental health clinic populations and about 20% in psychiatric inpatients. The young adult years are the hardest, but Borderlines in their 30s and 40s generally gain greater stability in their relationships and have less likelihood of suicide.

It's a long post, I know, but there's a lot going on with this disorder. Hopefully you'll find what you need if you're seeking info on BPD.

Q4U: Discuss any experience you've had with a Borderline. Did they seem to straddle the fence between sanity and insanity?