Borderline Personality Disorder

Borderline Personality Disorder is a mental health condition that has gotten increasing attention in the past 30 years. Although the concept had been recognized for many decades, the modern use of the term begin with Adolf Stern in 1938 to describe individuals suffering from a disturbance that was “on the borderline” between neurosis and psychosis.1 The condition was studied and written about intensively beginning in the 1970s, and is now thought to be a combination of disorders of emotional functioning, impulsive behavior, and unstable interpersonal relationships. It has also been referred to as “emotionally unstable personality disorder.2

PREVALENCE

Researchers have found that the prevalence in the overall population is estimated at 1.4 percent for Borderline Personality Disorder. They have also found that, in general, people with personality disorders are very likely to have co-occurring major mental disorders, including anxiety disorders (e.g., panic disorder, post-traumatic stress disorder), mood disorders (e.g., depression, bipolar disorder), impulse control disorders (e.g., attention deficit hyperactivity disorder), and substance abuse or dependence.3

SYMPTOMS

To qualify for the diagnosis, individuals need to exhibit two or more of the following:

  • Identity: Markedly unstable self-image, excessive self-criticism; chronic feelings of emptiness.
  • Self-direction: Instability in goals, aspirations, values, or career plans.
  • Empathy: Poor ability to recognize the feelings and needs of others, associated with interpersonal hypersensitivity (i.e., a tendency to feel criticized or insulted); perceptions of others biased toward the negative.
  • Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious fears of abandonment; close relationships often viewed in extremes of black and white, alternating between over-involvement and withdrawal.

And four or more of the following:

  • Emotional instability: Frequent mood changes; emotions that are easily aroused, intense, and out of proportion to circumstances.
  • Anxiousness: Intense feelings of nervousness or panic, often in reaction to interpersonal stresses; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
  • Separation insecurity: Fears of rejection by or separation from significant others, associated with fears of excessive dependency and complete loss of autonomy.
  • Depressivity: Frequent feelings of being down, miserable, and hopeless; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
  • Impulsivity: Acting on a momentary basis without a plan or consideration of outcomes; a sense of urgency and self-harming behavior under emotional distress.
  • Risk taking: Engagement in risky, and potentially self-damaging activities, without regard to consequences; denial of the reality of personal danger.
  • Hostility: Persistent or frequent angry feelings, especially in response to minor slights and insults.4

TREATMENT

To be maximally effective, treatment for Borderline Personality Disorder must be intensive, and often involves more than one professional. Typically, individual psychotherapy occurs twice per week or more, and focuses on helping the patient develop greater understanding of her/his condition, how it results in self-defeating patterns of behavior, and how to prevent that from happening with insufficient thought. Medication can be very helpful in offering patients greater control of moods and impulsivity. Group therapy is sometimes employed to assist patients in feeling more comfortable and less alone in their struggle to stabilize moods and relationships.

An approach that has gained much attention recently is Mentalization Based Treatment (MBT), pioneered by Peter Fonagy and Alan Bateman, which has many ties to contemporary theories of infant attachment. MBT is based on ideas that some individuals are genetically vulnerable to a lack of adequate positive emotional involvement and empathic mirroring during infancy, which results in the inadequate development of abilities to mentalise, especially in close interpersonal relationships. This is especially true of patients diagnosed with Borderline Personality Disorder, where they struggle to accurately empathize with the thinking and feelings of others in their lives. The primary goals of MBT are to improve mentalisation skills, by helping patients to understand and resolve the inaccurate internal perceptions they experience in relationships and to replace them with more realistic perceptions and emotions by learning to become more accurately empathic to others, including towards the therapist. This allows them to begin to develop a more confident sense of self and more secure close relationships in their lives.5

Another influential approach has been Dialectical Behavior Therapy (DBT), which was pioneered by psychologist Marsha Linehan. This is often involves a combination of individual and group psychotherapies, using a variety of techniques, including cognitive behavioral therapy, supportive defense-building psychodynamic psychotherapy, and family therapy.6

In my practice, I use these approaches as well as others, in a manner custom-designed to fit the individual patient and her/his needs, in order to maximize efficiency and positive results. The patient and I work closely together, as frequently as necessary, to gain control of powerful, urgent emotions and impulses, and to stabilize close interpersonal relationships so that life can progress in a way that fits with one’s goals and aspirations.

Contact Dr. Tom Bonner to discuss the evaluation and treatment of Borderline Personality Disorder.

REFERENCES (for further reading)

1Stern, Adolf (1938). “Psychoanalytic investigation of and therapy in the borderline group of neuroses”. Psychoanalytic Quarterly 7: 467–489.

2Emotionally unstable personality disorder – International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) – World Health Organization

3Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication Biol Psychiatry. 2007 Sep 15;62(6):553-64.

4John M. Oldham, M.D. Personality Disorders & DSM-5 Presentation for NEA-BPD Call-In Program Sunday, December 16, 2012, retrieved from http://www. borderlinepersonalitydisorder.com/wpcontent/uploads/2012/12/2012_December _16_v2.pdf

5Fonagy, P.; Bateman, A. (2004). Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment. Oxford University Press.

6Linehan, M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.