Borderline Personality Disorder
This is an essay I wrote for Abnormal Psych, I really enjoyed the opportunity to share some of my personal experiences being diagnosed with BPD.
Our textbook states that research is ongoing to try and figure out the genetic components of BPD, which appear to exist due to a higher rate of the disorder in identical twins. The links between serotonin levels, the limbic system, and emotional instability present in BPD is also being investigated. (470) A study on differences in amygdala structure in Borderline patients published in June 2018 concluded there appears to be, “an involvement of amygdala regions in aggressiveness of male BPD patients that are particularly related to social information processing and associative emotional learning.” It was interesting to see that for female patients with BPD, although their aggression was higher than that of the male and female healthy control group, their amygdalas showed no significant difference in size or shape. (Mancke,2018)
It has been shown that the symptoms of BPD are often the result of childhood trauma such as abuse and neglect. “In an important study, researchers followed 500 children who had documented cases of chilhood physical and sexual abuse and neglect and compared them in adulthood with a control group...Significantly more abused and neglected children went on to develop borderline personality disorder compared with controls.” (Barlow, 471) A study published in March of this year corroborates this statement. “One risk factor for the development of BPD is severe childhood maltreatment.” (Krause-Utz, 2019) According to Krause-Utz, et al, the way that Borderline is currently understood shows that the triple vulnerability theory does fit this disorder. There is a generalized biological vulnerability (serotonin levels, limbic system), a generalized psychological vulnerability (the tendency to react strongly to real and perceived threats) and a specific psychological vulnerability (early environmental experiences with abuse/neglect). They also point out that Linehan’s biosocial theory “emphasizes the role of an invalidating environment in the development of emotion dysregulation and impulsivity.” (KU,2019)
Borderline Personality Disorder is defined by the APA as, “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.” (Barlow, 470) At least five out of nine criteria must be met in order to receive a diagnosis. Criteria number one is “Frantic efforts to avoid real or imagined abandonment.” In my lived experience as a person with BPD, this can include what my therapist and I call the push/pull effect. I crave relationship, but I have trouble trusting that people will stay. The result is that sometimes I will pull away, act out, and /or have emotional outbursts before they can leave me of their own accord. I will give them a reason to go away, and then I can claim control over that. There is also a need for constant reassurance that your friends, family, and significant others do love you and you are not a bother to them. Other criteria almost cause a self fulfilling prophecy in that they create the type of environment that make close relationships very difficult to maintain.
The second criteria is a history of intense and unstable interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Everything is all or nothing for BPD sufferers. Their relationship is the best, most amazing, perfect thing to ever happen or it’s the worst thing ever. They are totally in love and euphoric, or they feel that their partner hates them and just can’t wait to get away. There is no understanding of middle ground and just sitting with sad feelings until they pass.
Criteria number three is Identity disturbance: markedly and persistently unstable sense of self-image or sense of self. Many people with Borderline have a feeling of just not knowing who they are. They tend to latch on to the hobbies and passions of whoever they are in a relationship with at the moment. Interestingly, according to research article “The lived experience of recovery in borderline personality disorder: a qualitative study”, the ability to somewhat identify with the borderline diagnosis but not too much, is an important step in reaching what is sometimes called remission. “Acceptance of the illness is required to a degree to progress in recovery in BPD. Over-identification, however,can also lead to stagnation in recovery.” (Ng, 2019) One of the subjects of this study in the not recovered group stated, “Sometimes I feel like my whole identity has been based around my trauma...when you suddenly start being able to react differently to things, I kind of felt like a lot of my identity was disappearing, because I no longer feel as intense”. Another patient, this one from the recovered group, said, “...I lacked an identity. I still don’t understand what identity is...I held onto that diagnosis for such a long time, that was who I was.”
The next criteria is a big one. Impulsivity in at least two ares that are potentially self-damaging, for example spending,sex,substance abuse,binge eating. Self harm and suicidal behavior are not to be included here as that is a separate criteria. “Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties” takes a close look at the facets of impulsive behavior in BPD. They used the Impulsive Behavior model by Whiteside and Lynam which describes it in four parts: lack of premeditation, increased sensation seeking, lack of perseverance, and urgency. (Krause-Utz, 2019)This type of impulsivity highlights the lack of thinking through the action and understanding the results ahead of time that occurs with BPD. This goes hand in hand with other criteria I will be discussing that deals with emotion regulation difficulties.
Criteria five is recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. This is very common in BPD according to the Substance Abuse and Mental Health Services Administration. Their research says that almost 80% of those diagnosed with BPD have had suicide attempts. Self-harm is often thought of as cutting, but can include other things like burning or hitting oneself, skin picking, and hair pulling.
Affective instability due to a marked reactivity of mood is the sixth criteria. These episodes can last a few hours to a few days and include intense feelings of irritability or anxiety. From my personal experience, the slightest thing would set me off such as a sudden realization that my home was a mess or dropping something by accident. Closely related is the criteria of inappropriate and intense anger or difficulty controlling anger. This may result in frequent physical fights, abusive behavior towards those close to the patient, temper tantrums, and constant anger.
The final criteria are chronic feelings of emptiness; and stress-related paranoid ideation or severe dissociative symptoms. Paranoid ideation is a feeling of persecution or harassment. You may feel that your boss or coworkers hate you and are talking about you behind your back for instance. Dissociation is when there is a separation between the self and the memories,behaviors,feelings, and/or perceptions. There are different ways that this can occur. Some people feel like they have lost time for example many adults with Borderline don’t remember pieces of their childhood. There can be a feeling of separation from your own body, like you are sort of floating around outside of yourself.
More women are diagnosed with BPD than men, although we do not know if that is genuine or because of gender expectations. In general, men’s aggression and tempers are more acceptable in society which may lead to a higher likelihood that women would be diagnosed. As discussed earlier in this summary, the rate of children that experience abuse and neglect who go on to be diagnosed with BPD is higher than children who have not had that experience. The incidence within the United States in the general population is 1-5% but approximately 20% of psychiatric inpatients. This is related to the high hospitalization rates of those with BPD due to suicidal ideation, “72% of patients who meet criteria for the disorder will be hospitalized at least once” (Bloom, 2012). More research needs to be done to discover true rates of personality disorders in general among varied races and ethnic groups. BPD is mostly found in women in early adulthood through their late thirties. After this point, many do begin to find their symptoms lessening.
The most common treatment for BPD is Dialectical Behavior Therapy (DBT) which was created by Marsha Linehan, herself diagnosed with Borderline. Common forms of performing this therapy include weekly therapy sessions, group skills training, and phone consultation outside of regular sessions. Treatment teaches clients coping strategies for stress, mindfulness, regulation of emotions, and interpersonal communication. Consultation outside of regular sessions is of importance for BPD patients because this helps to promote the ability to ask for help and develop a bond with their therapist. Bloom, et al found that across 11 studies, DBT improved symptomology in nine areas: self harm behaviors, depressive symptoms,dissociative experiences, anxiety symptoms, anger and hostility, suicidal ideation, violent behavior, global adjustment, and identity disturbance. (Bloom,2012) There are other areas of treatment which do not have as much research yet such as schema therapy, self-compassion and mindfulness training,mentalization-based therapy, and transference-focused therapy. (Krause-Utz, 2019) Ng, et al found that recovery from BPD has three main stages: Feeling stuck, diagnosis, and improving experience. They then identified three areas within the final stage: developing greater awareness of emotions and thoughts, strengthening the sense of self, and understanding the perspectives of others. From the interviews of those in the recovered and not recovered groups, this qualitative study concluded that there are four recovery processes: active engagement in the recovery process, hope, treatment, and meaningful activities and relationships. (Ng, 2019) How these processes are negotiated by the individual can determine if they self-identify as recovered or not. This study pointed sometimes a client may no longer fulfill criteria for a diagnosis, but they identify as not being recovered. I look forward to further research into the recovery process of BPD from the patient's perspective.
REFERENCES
Barlow, D. H., Durand, V. M., Lalumiere, M. L., & Hofmann, S. G. (2018). Abnormal psychology: An integrative approach. Toronto, Ontario: Nelson Education.
Bloom JM, Woodward EN, Susmaras T, & Pantalone DW. (2012). Use of dialectical behavior therapy in inpatient treatment of borderline personality disorder: a systematic review. Psychiatric Services, 63(9), 881–888. https://doi.org/10.1176/appi.ps.201100311
Krause-Utz,Annegret; Ezgi Erol,Athina V. Brousianou, Sylvia Cackowski, Christian Paret, Gabriele Ende, & Bernet Elzinga. (2019). Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties. Borderline Personality Disorder and Emotion Dysregulation, (1), 1. https://doi.org/10.1186/s40479-019-0101-8
Mancke, F., Herpertz, S. C., Hirjak, D., Knies, R., & Bertsch, K. (2018). Amygdala structure and aggressiveness in borderline personality disorder. European Archives of Psychiatry and Clinical Neuroscience, (4), 417. https://doi.org/10.1007/s00406-016-0747-9
Ng, Fiona Y. Y., Michelle L. Townsend, Caitlin E. Miller, Mahlie Jewell, & Brin F. S. Grenyer. (2019). The lived experience of recovery in borderline personality disorder: a qualitative study. Borderline Personality Disorder and Emotion Dysregulation, (1), 1. https://doi.org/10.1186/s40479-019-0107-2
Sack, D., MD. (2015, December 21). The Destructive Power of Borderline Personality Disorder. Retrieved July 27, 2019, from https://www.psychologytoday.com/us/blog/where-science-meets-the-steps/201512/the-destructive-power-borderline-personality-disorder
