Borderline personality disorder, or BPD, is a psychiatric disorder characterized by mood instability, impulsive behavior, intense feelings of anger and fears of retaliation, and difficulties with relationships. Oftentimes there are desperate needs and rapid emotional involvement with others followed by fears of dependency and a defensively motivated withdrawal. The symptoms usually appear in adolescence or young adulthood, but may begin to be evident in childhood.
Risk Factors for BPD
The precise causes of borderline personality disorder are unknown, but there seem to be environmental factors at play in the development of the condition. The lack of an early, safe, and stable environment is thought to lead to an inability to establish secure and lasting intimate relationships. This is compounded with an intense fear and distrust of others. In early development it is not uncommon to hear stories of a caregiver who would withdraw emotional support and love when the child attempted to separate and define him or herself. The caregiver's emotional unavailability prevents the achievement of a stable sense of self.
As with other psychiatric disorders, environmental disturbances may increase the patient‘s risk of developing the disorder. Environmental risk factors for BPD include:
- Sexual abuse
- Abandonment or traumatic loss during childhood
- Unstable family relationships
- Emotional abuse
- A caregiver who suffers with a personality disorder
Symptoms of BPD
While patients with BPD present as troubled personalities it is important to keep in mind that every symptom is an attempt to solve a problem. Because of their constant fear of abandonment, their doubts about self-worth, and their inability to be alone, they are often unable to establish or maintain comfortable relationships. Once involved in a relationship, patients with BPD tend to become obsessive, either idealizing or totally devaluing the other person. There are desperate and constant demands for attention and other forms of love along with an inability to accept and integrate the love and comforting that is offered. Because of the intense clinging and subsequent rejection of love, relationships are oftentimes volatile and abusive. Other symptoms, each of which represents a unique way to solve an unknown problem, include but are not limited to:
- Self Injury
- Feelings of emptiness, boredom or dissociation
- Suicidal threats
- Impulsive, risk-taking behavior
- Inappropriate explosive anger
- Extreme emotional reactions to ordinary events
- Intense and stormy relationships
- Paranoid thoughts or feelings
- Distress over minor separations
A very high percentage of patients with BPD are troubled by other psychiatric disorders as well. Female patients with BPD often present with major anxiety, depression, or eating disorders, while male patients with the condition are frequently substance abusers or have a dual diagnosis or BPD and narcissistic personality disorder (NPD).
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Diagnosis of BPD
Borderline personality disorder is often difficult to diagnose because there are different sub-types of BPD. Individuals with BPD may present as angry, confused, hopeless, anxious, or entitled. Some of these individuals may complain of feeling depressed and helpless. Careful assessment may reveal an unrelenting need to attack, depreciate and devalue oneself. Other individuals may have the need to attack, depreciate and devalue anyone who tries to get close to them or anyone who challenges their convictions. These patients with BPD believe their trouble is caused by other people or do not perceive that their own behaviors play a role in their problems. Skilled mental health care professionals are usually able to diagnose BPD after a thorough psychological assessment.
Treatment of BPD
In my practice, the treatment approach depends on the BPD sub-type. Each individual with BPD requires a unique treatment approach, based on the presenting problems. Having said that, one common treatment denominator is time. Successful treatment of BPD typically takes time, months and years, not weeks. I often meet with these patients as frequently as possible, multiple times per week is ideal and in my experience works best. Usually we can address the problems mentioned above in the therapy, but at times, and in rare situations, medication is used as an adjunct to the psychotherapy treatment process. There are advantages and disadvantages to going on medication, all of which I review closely with my patients so I can help them make an 'informed' decision.
Medications
No medication has been approved to treat the disorder itself, but medications may be prescribed to provide relief from symptoms of anxiety, depression or mood instability.
Psychotherapy
The therapy I offer is designed to guide patients to be aware of their behavior in the present, to reduce their (self) destructive impulses, to change their damaging belief systems which are persecutory in nature and to improve their interpersonal interactions. For those who commit to a course of treatment, when things go accordingly, the outlook is hopeful.
Risks of BPD
Poor judgment and impulsivity may result in patients with BPD putting themselves at risk. Unfortunately, a patient with this disorder is much more likely to be a victim of rape or other violent acts than the average person. Such patients are also at increased risk of attempting or committing suicide.