Borderline Personality Disorders
BORDERLINE PERSONALITY DISORDER
Diagnosis
A person with a borderline personality disorder often experiences a repetitive pattern of disorganization and instability in self-image, mood, behavior and close personal relationships. This can cause significant distress or impairment in friendships and work. A person with this disorder can often be bright and intelligent, and appear warm, friendly and competent. They sometimes can maintain this appearance for a number of years until their defense structure crumbles, usually around a stressful situation like the breakup of a romantic relationship or the death of a parent.
Symptoms
Relationships with others are intense but stormy and unstable with marked shifts of feelings and difficulties in maintaining intimate, close connections. The person may manipulate others and often has difficulty with trusting others. There is also emotional instability with marked and frequent shifts to an empty lonely depression or to irritability and anxiety. There may be unpredictable and impulsive behavior which might include excessive spending, promiscuity, gambling, drug or alcohol abuse, shoplifting, overeating or physically self-damaging actions such as suicide gestures. The person may show inappropriate and intense anger or rage with temper tantrums, constant brooding and resentment, feelings of deprivation, and a loss of control or fear of loss of control over angry feelings. There are also identity disturbances with confusion and uncertainty about self-identity, sexuality, life goals and values, career choices, friendships. There is a deep-seated feeling that one is flawed, defective, damaged or bad in some way, with a tendency to go to extremes in thinking, feeling or behavior. Under extreme stress or in severe cases there can be brief psychotic episodes with loss of contact with reality or bizarre behavior or symptoms. Even in less severe instances, there is often significant disruption of relationships and work performance. The depression which accompanies this disorder can cause much suffering and can lead to serious suicide attempts.
Etiology
It is a common disorder with estimates running as high as 10-14% of the general population. The frequency in women is two to three times greater than men. This may be related to genetic or hormonal influences. An association between this disorder and severe cases of premenstrual tension has been postulated. Women commonly suffer from depression more often than men. The increased frequency of borderline disorders among women may also be a consequence of the greater incidence of incestuous experiences during their childhood. This is believed to occur ten times more often in women than in men, with estimates running to up to one-fourth of all women. This chronic or periodic victimization and sometimes brutalization can later result in impaired relationships and mistrust of men and excessive preoccupation with sexuality, sexual promiscuity, inhibitions, deep-seated depression and a seriously damaged self-image. There may be an innate predisposition to this disorder in some people. Because of this there may ensue subsequent failures in development in the relationship between mother and infant particularly during the separation and identity-forming phases of childhood.
Treatment
Treatment includes psychotherapy which allows the patient to talk about both present difficulties and past experiences in the presence of an empathetic, accepting and non-judgemental therapist. The therapy needs to be structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways. Sometimes medications such as antidepressants, lithium carbonate, or antipsychotic medication are useful for certain patients or during certain times in the treatment of individual patients. Treatment of any alcohol or drug abuse problems is often mandatory if the therapy is to be able to continue. Brief hospitalization may sometimes be necessary during acutely stressful episodes or if suicide or other self-destructive behavior threatens to erupt. Hospitalization may provide a a temporary removal from external stress. Outpatient treatment is usually difficult and long-term - sometimes over a number of years. The goals of treatment could include increased self-awareness with greater impulse control and increased stability of relationships. A positive result would be in one's increased tolerance of anxiety. Therapy should help to alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality. With this increased awareness and capacity for self-observation and introspection, it is hoped the patient will be able to change the rigid patterns tragically set earlier in life and prevent the pattern from repeating itself in the next generational cycle.
Richard J. Corelli, M.D.
corelli@leland.stanford.edu
