Borderline Personality Disorder

Years ago I had the opportunity to work on the inpatient unit of a psychiatric hospital. It was gratifying to see how many of the patients recovered from psychotic episodes in a matter of 2 to 3 days, after medications helped bring their symptoms under control.

During that time, however, I also encountered patients whose difficulties did not respond to treatment as quickly. Many struggled with regulating their emotions; expressing anger or distress at an intensity level that was out of proportion. I still remember Ms. X, for example, whose explosive behavior brought her to the unit at least 6 times in a period of about 10 months.

Ms. X was a 23 year-old single, white female and it was obvious that neither psychotherapy nor medication was being effective for her. On several occasions she claimed that she cut herself with a knife in order to feel pain, so that she would feel “real.” Ms. X’s relationship with her parents was strained, and she had a history of tempestuous and brief romances. She had been involved with at least 5 or 6 boyfriends in the last year.

The doctors had diagnosed her with Borderline Personality Disorder (BPD) and had recommended psychotherapy and pharmacotherapy, including antidepressants and atypical antipsychotic medications. I remember how a well-trained therapist in the hospital had tried an approach used to treat patients with BPD; Dialectical Behavior Therapy. This approach seems to work well with these individuals as total acceptance on behalf of the therapist is necessary, due to the fact that the patients are extremely sensitive to criticism and rejection. These patients usually walk away from treatment the minute they sense a hint of rejection, and Ms. X was no exception.

Just as with other mental disorders, there are signs and symptoms of BPD that can help a mental health professional determine a diagnosis to facilitate treatment. In today’s world, no managed care company would authorize treatment unless there is a diagnosis. However, it is important to mention that authorization for treatment of Axis II personality disorders, such as BPD, is more and more challenging. Clinicians may use caution and care before diagnosing an individual with BPD because it can be difficult to determine the existence of this disorder from a single assessment or interview. Often an individual may not receive this diagnosis until treatment has progressed or an individual has been facing difficulties over a consistent and extended period of time. Unfortunately, the word “borderline” is often used negatively and pejoratively as a label which can marginalize and pathologize individuals who need effective treatment and support.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the diagnostic criteria for Borderline Personality Disorder are as follows:

“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. frantic efforts to avoid real or imagined abandonment.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. identity disturbance: markedly and persistently unstable self-image or sense of self.
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms

There is no doubt that many of the signs that Ms. X manifested (i.e. self-destructiveness, mood instability, and chaotic interpersonal relationships) resembled the diagnostic criteria for BPD described in the DSM. Oftentimes she was argumentative, irritable, and sarcastic.

The causes are not clear, but many researchers believe that BPD is linked to a combination of biological and environmental variables. Some even say that BPD runs in families. Whatever the reason, if you or someone you know identifies with some or several of the signs and symptoms described above, please talk to your doctor or seek help from a mental health professional in your area.

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