Borderline Personality

Mental illness characterized by erratic and impulsive self-destructive behavior and an intense fear of abandonment.

Characteristics

Borderline individuals have a history of unstable interpersonal relationships. They have difficulty seeing the "shades of gray" in the world, and view significant people in their lives as either completely flawless or extremely unfair and uncaring (a phenomena known as splitting). These alternating feelings of idealization and devaluation are the hallmark feature of borderline personality disorder. Because borderline patients set up such excessive and unrealistic expectations for others, they are bound to be disappointed when their expectations aren't realized.

The term "borderline" was originally coined by psychologist Adolf Stern in the 1930s to describe patients who bordered somewhere between psychosis and neurosis. It has also been used to describe the borderline states of consciousness these patients sometimes feel when they experience dissociative symptoms (a feeling of disconnection from oneself).

Causes and symptoms

Borderline personality disorder accounts for 30–60% of all personality disorders, and is present in approximately 2% of the general population. The disorder appears to affect women more frequently than men, and 75% of all diagnosed patients are female.

Adults with borderline personalities often have a history of significant traumas such as emotional and physical abuse, neglect, or the loss of a parent in childhood. Feelings of inadequacy and self-loathing that arise from these situations may be key in developing the borderline personality. It has also been theorized that these patients are trying to compensate for the care they were denied in childhood through the idealized demands they now make on themselves and on others as an adult.

In its Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a reference standard for mental health professionals, the American Psychiatric Association defines borderline personality as a long-standing pattern of instability and impulsive behavior beginning in early adulthood. DSM-IV states that at least five of the following criteria (or symptoms) must be present in an individual for a diagnosis of borderline disorder:

• Frantic efforts to avoid real or perceived abandonment.
• A pattern of unstable, and intense interpersonal relationships, characterized by alternating between idealization and devaluation (i.e., a "love-hate" relationship).
• Identity disturbance characterized by an extreme, persistently unstable self-image and sense of self.
• Impulsive behavior in at least two areas (e.g., spending, sex, substance abuse, reckless driving, binge eating).
• Recurrent suicidal behavior, gestures, or threats, or recurring acts of self-mutilation (e.g., cutting or burning oneself).
• Affective (mood) instability due to brief but intense episodes of dysphoria (depression), irritability, or anxiety.
• Chronic feelings of emptiness.
• Inappropriate and intense anger, or difficulty controlling anger displayed through temper outbursts, physical fights, and/or sarcasm.
• Transient, stress-related paranoia and/or severe dissociative symptoms (a separation from the subconscious, sometimes characterized by a "dream-like" state and physical symptoms such as flashbacks).

Diagnosis

Borderline personality disorder typically first appears in early adulthood. Although the disorder may occur in adolescence, it may be difficult to diagnose, as "borderline symptoms" such as impulsive and experimental behaviors, insecurity, and mood swings are also common, developmentally appropriate occurrences at this age.

Borderline symptoms may also be the result of chronic substance abuse and biologically based medical conditions (specifically, disorders of the central nervous system). These should be ruled out as causes before making the diagnosis of borderline personality disorder.

The disorder commonly occurs together with mood disorders (i.e., depression and anxiety), post-traumatic stress disorder, eating disorders, attention deficit/hyperactivity disorder (ADHD), and other personality disorders. It has also been suggested by some researchers that borderline personality disorder is not a true pathological condition in and of itself, but rather a number of overlapping personality disorders; however, it is commonly recognized as a separate and distinct disorder by the American Psychological Association and by most mental health professionals.

Treatment

Individuals with borderline personality disorder seek psychiatric help and hospitalization at a much higher rate than people with other personality disorders, probably due to their fear of abandonment and need to seek out idealized interpersonal relationship. These patients represent the highest percentage of diagnosed personality disorders (up to 60%).

Providing effective therapy for the borderline personality patient is a necessary, but difficult, challenge. The therapist-patient relationship is subject to the same inappropriate and unrealistic demands that borderline personalities place on all their significant interpersonal relationships. They are chronic "treatment seekers" who become easily frustrated with their therapist if they feel they are not receiving adequate attention or empathy, and symptomatic anger, impulsivity, and self-destructive behavior can impede the therapist-patient relationship.

However, their fear of abandonment, and of ending the therapy relationship, may actually cause them to discontinue treatment as soon as progress is made.

Psychotherapy, typically in the form of cognitive behavioral therapy, is usually the treatment of choice for borderline personalities. Dialectical behavior therapy (DBT), a cognitive-behavioral technique, has emerged as an effective therapy for borderline personalities with suicidal tendencies. The treatment focuses on giving the borderline patient self-confidence and coping tools for life outside of treatment through a combination of social skill training, mood awareness and meditative exercises, and education on the disorder. Group therapy is also an option for some borderline patients, although some may feel threatened by the idea of "sharing" a therapist with others.

Medication is not considered a front-line treatment choice, but may be useful in treating some symptoms of the disorder, and in alleviating the symptoms of mood disorders that have been diagnosed in conjunction with borderline personality disorder. Recent clinical studies have indicated that naltrexone, an opiate antagonist, may be helpful in relieving physical discomfort related to dissociative episodes.

Prognosis

The disorder usually peaks in young adulthood and frequently stabilizes after age 30. Approximately 75-80% of borderline patients attempt or threaten suicide, and between 8-10% are successful. If the borderline patient suffers from depressive disorder, the risk of suicide is much higher. For this reason, swift diagnosis and appropriate interventions are critical.