Focus Report: Borderline Personality Disorder

History of Borderline Personality Disorder

American psychoanalyst Adolph Stern was the first practitioner to describe “the borderline group” in 1938. In his description possible etiology and effective treatments were discussed. Most of the symptoms Stern laid out are included in the current DSM-IV TR. In the 1940’s Robert Knight introduced the concepts of Ego Psychology (Friedel, n.d.), which enables us to regulate our emotional functions to the social environment. Knight suggested that these functions were impaired in some people and referred to the impairments as “borderline states.”

Otto Kernberg proposed that mental disorders were determined by three personality organizations: psychotic, neurotic and “borderline personality.” (Friedel, n.d.), In 1968 Roy Grinker and his colleagues conducted and published research on patients with Borderline Personality Disorder which was referred to as “borderline syndrome.” In 1975 Gunderson and Singer published a groundbreaking article on borderline personality disorder that included a definition of major characteristics and diagnosis criteria. Gunderson then produced a specific research instrument that verified the validity of BPD. Because of Gunderson’s work borderline personality disorder appeared in DSM-III as a psychiatric diagnosis in 1980. (Friedel, n.d.)

In 1986 John Brinkley, Bernard Beitman and Robert Friedel experimented with low doses of neuroleptic drugs and found some promise for treating symptoms of BPD. In two placebo controlled studies they found positive effects. Pathophysiologists in the 1980’s experimenting with neuroimaging, biochemical, and genetic studies found evidence for a biochemical cause of BPD. In the 1990’s Marsha Linehan introduced Dialectical Behavior Therapy (DBT) which was specifically developed for BPD and targeted patients with self injurious behaviors and frequent hospitalization.

Two advocacy groups have been formed within the past ten years, the Treatment and Research Advancements Association for Personality Disorder (TARA APD) and the National Education Alliance for Borderline Personality Disorder (NEA-BPD). These groups seek to increase awareness of BPD, provide support to the sufferers and families of BPD, lobby to increase federal support for research, and to reduce the stigma associated with the disorder. (Friedel, n.d.)

Description of Borderline Personality Disorder

Borderline Personality Disorder is an intense and pervasive mental disease in which the symptomatology is suicidal and interpersonal. Individuals with this disorder make frantic effort to ward off abandonment whether real or perceived. Chaos defines the patient’s problem solving; their self image and self control are scattered by anger and recklessness. Affective instability, and notoriously difficult are key attributes of BPD. Terrifying for both families and practitioners is the consensus. BPD is characterized by a dualistic perception of relationships where loved ones and authority figures are idealized one minute, and devalued the next. The individual feels a chronic emptiness, and a severe sense that they are evil. Perfectionism meets self loathing in a downward spiral that if not interrupted will take everyone else concerned with it.

Differential Diagnosis

Since borderline personality disorder is thought of by some as a catch all diagnosis for a certain subset of people, the American Psychological Association Diagnostic and Statistical Manual of Mental Disorders (4^th ed.) Text Revision has devoted particular detail to distinguishing BDP from other personality and mood disorders.

The DSM-IV-TR, 2000 states:

Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the clinician should avoid giving additional diagnosis of Borderline Personality Disorder based only on a cross sectional presentation without having documented the pattern of behavior as an early onset and a long standing course.(p. 709)

Also:

You can differentiate Borderline Personality Disorder from Histrionic Personality Disorder by self destructiveness, angry disruptions in close relationships, feelings of emptiness, and loneliness. Paranoid ideas or illusion are more fleeting, interpersonally reactive, and responsive to external structuring in BPD than in Schizo-typal Personality Disorder. (DSM-IV-TR p. 709) Paranoid Personality Disorder and Narcissistic Personality Disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self destructiveness, impulsivity, and abandonment concerns distinguish these disorders from BPD. (DSM-IV-TR p. 710)

Individuals with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gain, whereas the goal in BPD is directed more toward gaining the concern of caretakers. BPD can be further distinguished from Dependant Personality Disorder by the typical pattern of unstable and intense relationships. (DSM-IV-TR p. 710)

Course of the Disorder

There is no standard course for BPD, which is to say that there are many divergent paths this personality can take. Lingering imbalance typifies early adulthood. With periods of intense interpersonal friction, and episodes of impulsivity, the patient is exposed to the medical system regularly and the mental health system constantly.

Generally the self destructive periods which include suicide attempts, self mutilation, drugs, and promiscuity, occur during the young adult years. As the patient ages, the symptoms ebb and become more subtle, suicide becomes less of a risk. That is not to say that all problems go away in the patient’s thirties. There is no time threshold denoting that the individual is magically cured. Rather at some point the disorder has resolved itself, either due to structured change in behavior and thinking, or a tragic consequence.

Relational intensity, impulsive behavior, and emotional extremes tend to be lifelong. When therapeutic and pharmacological methods are employed early or at a critical point improvement can be seen almost immediately. By the thirties or forties many patients with BPD have remarkable success in familial or professional situations, and go on to lead normal lives. There is hope!

Etiology of BPD

As we have discussed throughout Abnormal Psychology an integrated approach is most logical. “BPD is five times more common than among first-degree biological relatives of those with the disorder than in the general population.” (DSM-IV-TR) At the same time, statistically speaking, it is very rare to have BPD and no history of childhood abuse. (Durand & Barlow 2006) “Core dimensions of BPD appear to have neurobiological cause, most saliently evidenced as prefrontal cortex (PFC) dysfunction,” (Feske, Soloff, et al.) So we can infer that there is a biological and a social component to this disease.

Doctor Linehan of the University of Washington hypothesizes that the disorder is a consequence of an emotionally vulnerable individual growing up with a particular set of environmental circumstances which can be referred to as “the Invalidating Environment.” (Kiehn & Swales 2006) This means that children with genetically heritable low tolerances for stress have extreme autonomic reactions, and take longer to return to regular stress levels; these same children, if subjected to parenting that does not validate their emotions, and the observations of the child, can be pushed into this disorder. Certain stress thresholds must be breached. According to Linehan this same environment also places high expectations of self control and self reliance on the child. (Kiehn & Swales 2006) “She will neither have the opportunity accurately to label and understand her feelings nor will she learn to trust her own responses to events.” (Linehan 1993) This is further confounded by “Functional MRI studies in BPD have demonstrated abnormal responses to social cues (such as face recognition) in the amygdale, which increases the likelihood of inappropriate emotional and behavioral responding.” (Feske, Soloff, et al.)

The child’s affect will fluctuate in this environment between sublimation of feelings, in an attempt to gain favor, and all out tantrums in an attempt to have feelings recognized. (Kiehn & Swales 2006) “a particular consequence of this state of affairs will be a failure to understand and control emotions; a failure to learn the skills required for ‘emotional modulation’.” (Linehan 1993)

The question of abuse and sexual trauma can not be ignored; in Linehan’s model these abuses are considered “Invalidation” in the extreme. Also this would explain the patient’s lack of regulation in relational contexts. Another problem arising from sexual trauma is theoretical models that predict damage to the hippocampus similar to that occurring with PTSD. (Shire, Butler & Lewis 2005) “Structural studies using MRI have demonstrated volume loss in the hippocampus and/or amygdale in women with BPD.” (Feske, Soloff, et al.)

While these theories as put forth by Linehan are not empirically supported, the proof is in the pudding one might say. Doctor Linehan’s treatment modalities have proven successful at the University of Washington, and in other measured studies.

Treatment of BPD

"This man has not yet seen his last evening;

But, through his madness, was so close to it,

That there was hardly time to turn about"

(The Devine Comedy, Dante, [Canto I, Pergatorio])

The borderline patient is far from abandoning hope, but hangs precariously over the pit. Intervention and accountability is the key. BPD is difficult for everyone involved, especially the therapist; this due to the comorbidity of BPD with substance abuse, and mood disorders. Repeated suicide attempts are the extenuating cofactors that lead to caregiver burnout. Again an integrated or holistic approach utilizing psychotherapy, cognitive therapy, and pharmacology proves logical.

Pharmacology, despite many opinions, has a measurable positive impact on BPD. While there is no evidence any drug will prevent suicide, (Paris, 2006) other areas of the disorder can be regulated successfully. (Triebwasser & Siever, 2006)

Currently the most proven drugs are (SNRIs) serotonin-norepinephrine reuptake inhibitors, and (SSRIs) selective serotonin reuptake inhibitors, usually fluoxetine. These anti depressants have shown in placebo trials to affect rage, irritability, aggression and general clinical complaints. (Triebwasser & Siever, 2006) It is interesting to note that in control groups receiving Dialectical Behavior Theory these drugs showed little impact.

Anticonvulsants have shown great promise and it is theorized that this is due to BPD “anger attacks” being similar in physiologic function to a seizure; patients often describe the attacks as sudden and irresistible. (Triebwasser & Siever, 2006)

Antipsychotic drugs are the most controversial, and they have replaced the neuroleptic drugs after two studies showed haloperidol, a neuroleptic, to be ineffective. (Triebwasser & Siever, 2006) Studies showed olanzapine and aripiprazole superior to placebo in controlling anxiety, anger, paranoia, hostility, impulsivity and aggression.

In the borderline patient suicide is chronic and not acute, the function serves to provide a sense of control. Since the patients can not control life, they control death. Suicide attempts serve to punish others, escape suffering, and to communicate distress. (Paris, 2006) The caregiver should not apply methods used to control acute suicide when approaching chronic suicide. Active suicide interventions tend to reinforce negative borderline behaviors; the caregiver must tolerate suicide and focus on the behaviors that cause it. (Paris, 2006)

By far the most proven effective treatment has been (DBT) dialectical behavior theory. This approach trains the borderline to modulate emotions and evaluate extremes in thinking. The borderline symptoms present as an assertion which is seen as a “thesis” an opposing position must be formulated “antithesis.” Both thesis and antithesis are extremes typically, so the patient must seek the “synthesis” a median between two extremes. Teamwork is the model of the client / therapist relationship, the client must accept certain facts and weaknesses of the therapist, and the therapist must do the same for the client. Assumptions have to be made; the patient wants to change, and her behavior is not her fault, the behavior is understandable given the background of the patient, patients can not fail, if things do not improve the treatment is failing, the patient must never be referred to in a pejorative attitude. (Linehan 1993) Agreements must be made and the patient must understand the fact that “Sometimes therapists are jerks.” (Linehan 1993)

DBT utilizes four modes of treatment; individual therapy, group skills training, telephone contact, and therapist consultation. Individual therapy is the core of the treatment, and is broken down into a series of stages and a subset of targets designed to alter thinking and behavioral patterns. The strategies of DBT are; contingency management, cognitive therapy, exposure based therapies, and pharmacotherapy.

Two major trials have established the effectiveness of DBT (Linehan et al, 1991) compared the effectiveness of DBT relative to (TAU) treatment as usual at one year the control group had significantly more inpatient psychiatric days compared to the DBT group. (38.6 days per year for control; 8.46 days for the DBT group.) One should note that even though the DBT group was successful in three measurable areas; suicidality, inpatient days, and treatment compliance, there was no difference between the control and the DBT group, when evaluating mood and suicidality questionnaires.

Biblical Critique of BPD

“Train up a child in the way he should go: and when he is old, he will not depart from it.” (Proverbs 22:6) In mainstream Christianity there is very little acceptance for those people who use bad parenting as an excuse for bad behavior. But empirical data supports the fact that childhood trauma leads to adult misery. Fault is a term not to be bandied about lightly. The BPD sufferer is not to blame for the emotional trauma of their youth, but their weaknesses are still their faults, just like a vase with a crack suffers from its own fault. The borderline must take responsibility. In Luke chapter eight we met a woman who had spent her savings on doctors, she was trying to heal an issue of blood. The borderline has a multitude of issues from the mind, if she seeks help, Jesus’ answer to the BPD patient will be the same: “Daughter, be of good comfort: thy faith hath made thee whole; go in peace.” (Luke, 8:48)

References

American Psychological Association Diagnostic and Statistical Manual of Mental Disorders (4^thText Revision ed.)

Friedel, Robert O. (n.d.). Borderline Personality Disorder Demystified WHAT IS BPD, History. Retrieved October 22, 2007, from http://www.bpddemystified.com/

Horner, A.J. (1976). Oscillatory Patterns of Object Relations and the Borderline Patient.

Int. R. Psycho-Anal., 3:479-482.

Kiehn, B. & Swales, M. (n.d.) An Overview of Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder.

Retrieved October 17, 2007, from http://www.priory.com/dbt.htm

Tribewasser, J. & Siever, L. J. (2006) Pharmacology of Personality Disorders. Psychiatric Times, pg. 34-41

Paris, J. (2006) Managing Suicidality in Patients With Borderline Personality Disorder, Psychiatric Times, pg. 34-42

Feske, U., Soloff, P. & Tarter, R. (2007) Implications for Treatment and Prognosis of Borderline and Substance Use Disorders, Psychiatric Times, pg. 41-49

Kreisman, J.J. & Straus, H. (1989) I Hate You – don’t leave me: Understanding the Borderline Personality. New York, New York: Avon Books.

Linehan M.M. (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York, New York: the Guilford Press.

Durand M. V. & Barlow D. H. (2006) Essentials of Abnormal Psychology (4^th ed.). Belmont, California: Thomson Higher Education.