Borderline Personality Disorder

WHAT IS BORDERLINE PERSONALITY DISORDER?

Borderline personality disorder is characterized by emotion dysregulation, meaning quick, frequent, and painful mood swings that are beyond the control of the person with the problem.^{1, 2} People struggling with this problem have great difficulty forming and maintaining relationships.¹ They also experience problems controlling their own spontaneous and reckless behaviors and often have a fluctuating idea about who they are.^{1, 3} The overall theme for this disorder is rapid and unpredictable changes in a person’s thoughts, moods, behaviors, relationships, and beliefs.^{4, 5}

Very often, these rapid changes are caused by recurring fears of being criticized or deserted by other people, or they are triggered by actions of other people that feel like criticism, such as small disagreements or changes in plans.¹ In response to these types of situations, a person with borderline personality disorder can suddenly become very sad, nervous, angry, or short-tempered.³ The person might also practice self-harming behaviors, like cutting himself or herself, or engage in suicidal acts. Unfortunately, personality styles like this often create problems in a person’s relationships, job, and other social situations, which is why they’re referred to as personality disorders.

People who suffer with borderline personality disorder often have histories of intense relationships that begin and end very suddenly. Frequently, this is caused by two things: their fear of being abandoned and their tendency to quickly idolize and then criticize other people. For example, a female student with borderline personality disorder quickly formed a very intense relationship with another student she met in class. Immediately, the young woman wanted to spend all of her free time with the other student and spoke very highly of her new “best friend.” However, the first time the other student declined an offer to socialize, the young woman felt intensely afraid and hurt. She suddenly suspected that her new friend was abandoning her and lashed out at the other student, berating her and accusing her friend of deserting her. Understandably, the other student ended the relationship.

For people struggling with borderline personality disorder, episodes like this happen frequently and can be very overwhelming. Intense emotions such as fear, hurt, anxiety, anger, sadness, and shame can last for a few hours to as long as a few days. In response to feeling abandoned or hurt, the person with the disorder might do something extreme (or threaten to do something extreme) in an attempt to keep the other person from leaving. Using the previous example, the student with borderline personality disorder might begin to repeatedly call her friend in an attempt to convince her to continue the relationship. In very desperate situations, the person might even threaten suicide if the other person doesn’t do what is requested, as in “Don’t leave me—or else.”³

However, people with borderline personality disorder also tend to lash out at themselves when they’re feeling angry and overwhelmed. Some people engage in activities such as cutting on their arms and legs and other forms of self-mutilation. Others might use drugs and alcohol excessively, engage in unsafe sexual encounters, go on shopping sprees they can’t afford, gamble excessively, or engage in unhealthy eating habits like bingeing and purging.⁴ In more hopeless situations, the person might attempt suicide or think about suicide in a detailed way.

Most people with this problem are constantly examining their relationships for problems and expecting to be deserted by other people.⁶ They also tend to categorize themselves, others, and things into classes of either “all good” or “all bad,” with no middle ground in between.³ This is why small problems can often lead to the end of a relationship. Yet, despite how quickly their relationships end, many people with borderline personality disorder are actually afraid of being alone because they think they’re not capable of coping with problems by themselves.6

Battling borderline personality disorder can be very tiring and confusing. People with this problem are in severe physical,⁷ emotional,² and psychological pain⁸ almost all the time. They also lack a stable sense of who they are.¹ One minute the person might think of himself or herself as a good person, and the next minute think of himself or herself as evil and flawed. Thoughts about other people fluctuate rapidly, as well. The person might want to trust others, but at the same time, he or she doesn’t think other people are trustworthy.⁶ All of this confusion can very easily leave a person feeling empty, sad, and hollow inside.

Adding to the bewilderment of the disorder, people struggling with borderline personality disorder might sometimes feel as though they leave their bodies during times of stress and can’t recall what happened. These severe periods of dissociation only add to their unstable sense of self. Similarly, and equally disturbing, are periods of hallucinations that can occur during times of stress or depression.^{1, 9}

ARE THERE OTHER PROBLEMS RELATED TO BORDERLINE PERSONALITY DISORDER?

Of all the problems related to borderline personality disorder, the most severe is suicide. It’s estimated that as many as 75 percent of people with this disorder will attempt to kill themselves at some point,¹⁰ and as many as 10 percent eventually will take their own lives.^11-14 Not surprisingly, it seems that the level of emotional instability is the most accurate predictor of suicide, rather than the person’s level of depression.¹⁵

Many people with borderline personality disorder also suffer with depression, dysthymia, post-traumatic stress disorder, eating disorders, social phobia, specific phobia, panic disorder, and drug and alcohol problems.^16-19 Males suffering from the disorder seem to be more likely to develop drug or alcohol problems than female sufferers, whereas females with the disorder appear to be more likely to develop bulimia, anorexia, and other eating disorders.^{19, 20}

People with borderline personality disorder also frequently suffer with other personality disorders, such as a dependent personality and an extreme suspicion of others (paranoid personality disorder).²¹ In addition, they often endure chronic medical conditions such as fibromyalgia, chronic fatigue syndrome, obesity, diabetes, hypertension, arthritis, and back pain.⁷

WHO IS AFFECTED BY BORDERLINE PERSONALITY DISORDER?

Studies have estimated that approximately 1 to 5 percent of the general population is affected by borderline personality disorder,^22-25 while as many as 15 percent of psychiatric hospital patients are thought to be affected.²⁶ The disorder sometimes begins as early as childhood or adolescence,²⁷ but many people first seek treatment around the age of eighteen.²⁸ Many studies report that almost 75 percent of the people diagnosed with borderline personality disorder are women.^{25, 26} However, this striking outcome isn’t always found,^{20, 22} and a few researchers have uncovered evidence that some mental health care professionals diagnose women with borderline personality disorder more frequently than men, even when both sexes have the same symptoms.^{29, 30}

WHAT CAUSES BORDERLINE PERSONALITY DISORDER?

The exact causes of borderline personality disorder are unknown, but most likely it is the result of biological, psychological, and social risk factors.³¹ In general, personality problems like this one have a strong chance of being passed on in families due to influential genetic factors that can be inherited.³² Certain personality traits, including emotional instability, also appear to be highly inheritable.³³ Using brain-imaging technology, researchers have determined that certain behaviors related to borderline personality disorder, such as impulsivity, are related to low levels of the brain chemical serotonin.³⁴

Using similar techniques, researchers also found that people with borderline personality disorder interpret other people’s facial expressions in an overreactive way when compared to people without the disorder.³⁵ This makes it hard for some people to interpret neutral facial expressions, and sometimes it leads them to misinterpret neutral faces as having threatening expressions. In addition, some brain-imaging studies have found that people diagnosed with borderline personality disorder also exhibit smaller sizes in certain brain areas involved with emotional functioning.^{36, 37}

The most alarming research findings have linked borderline personality disorder with a history of being abused, especially sexual, physical, emotional, and verbal abuse.³⁸ In one study, 91 percent of those with borderline personality disorder had been the victim of some type of abuse and 92 percent had experienced severe neglect as a child.³⁹ In another study, 40 percent had been sexually abused,⁴⁰ with both men and women affected.^{41, 42} In many cases, the victims reported being sexually and physically abused as children by more than one person.^{43, 44} In another report, 50 percent of the people with borderline personality disorder reported being sexually abused as children on a weekly basis for at least one year by a parent or a friend of the family.⁴⁵ In this same study, it was discovered that the severity of the sexual abuse and overall neglect was related to the severity of the disorder. Similarly, in another study, the severity of the sexual abuse was proportional to the victim’s history of suicidal behavior.⁴⁶

Yet, despite how devastating these abusive events can be to an individual, not everyone who experiences them will develop borderline personality disorder.⁴⁷ One theory suggests that those who develop the disorder are naturally defenseless against emotional reactions and unable to react in a healthy and helpful way to emotional experiences.³ This vulnerability is then made worse when the person is placed in an abusive situation, like those just described. Similarly, when children grow up with abusive parents who continually criticize them and invalidate their emotions, it’s not hard to imagine why they may grow up very confused and doubtful about their own emotional reactions.

WHAT TREATMENTS ARE EFFECTIVE FOR BORDERLINE PERSONALITY DISORDER?

The treatment of borderline personality disorder requires a long-term commitment. On average, most people with this disorder go to at least six mental health care professionals looking for the right person to help them.^{48, 49} Many seek individual psychotherapy, group therapy, or family therapy, but in severe cases hospitalization or inpatient care may be necessary.4 Many types of treatments have been used to help people with this problem. Among them, psychodynamic therapy has been shown to be effective in some cases.^{50, 51}

However, the treatment that has received the most validation for its effectiveness is dialectical behavior therapy,^{3, 52-54} which was developed specifically to treat borderline personality disorder. This treatment has been shown to relieve symptoms of the disorder, decrease the tendency to commit suicide,^{55, 56} and decrease the tendency to misuse drugs.^{57, 58} This last factor is especially important because, in one study, the absence of an alcohol or drug problem was the best predictor of symptom reduction.¹⁸

Dialectical behavior therapy balances a person’s need for change with an acceptance and understanding of his or her current behavior.3 The treatment aims to broaden the person’s ability to be mindful of the present and decrease self-harming behaviors, while also teaching the person skills to regulate emotions, behaviors, and thoughts.

Many people with borderline personality disorder are also prescribed multiple medications.⁵⁹ For example, small studies of certain antidepressants have demonstrated some benefits. Fluvoxamine (Luvox) can decrease quick mood changes,⁶⁰ while fluoxetine (Prozac) can decrease impulsive anger⁶¹ and impulsive hostility.⁶² Studies of antipsychotic medications, such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa), have also shown some benefits, including reduced hallucinations,⁶³ reduced self-harming behaviors,⁶⁴ reduced hostility and depression,⁶⁵ and an overall feeling of improvement,⁶⁶ especially when used in conjunction with dialectical behavior therapy.⁶⁷

Similar small studies have supported the use of the mood stabilizer valproic acid (Depakote),⁶⁸ the anticonvulsant topiramate (Topamax),⁶⁹ the anticonvulsant lamotrigine (Lamictal),⁷⁰ and omega-3 fatty acids⁷¹ for reducing hostile behavior in people with borderline personality disorder. (Click here for information about the use of medications.)

DIALECTICAL BEHAVIOR THERAPY FOR BORDERLINE PERSONALITY DISORDER

Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy. Both types of treatment examine the way in which thoughts, feelings, and behaviors interact and affect each other. However, a psychotherapist who uses DBT is especially interested in learning how a person’s thoughts can create disruptive behaviors and emotions that interfere with the person’s life and relationships. After examining these interactions, a DBT therapist will help the person modify thoughts, feelings, and behaviors using different types of skills training.

The term “dialectic” refers to the examination of opposing thoughts and behaviors that takes place in DBT. For example, one of the fundamental techniques of the treatment is to teach people how to accept themselves, with all of their problems, while simultaneously acknowledging that some basic changes are needed in order for their lives to improve.

The DBT treatment of borderline personality disorder is usually composed of six steps:³

Conduct an assessment and provide education
Develop distress tolerance skills
Develop mindfulness skills
Develop emotion regulation skills
Develop interpersonal regulation skills
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step in the dialectical behavioral treatment for borderline personality disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with borderline personality disorder and not some other similar problem. Once people have been diagnosed with the disorder, it’s also important that they understand the basic nature and causes of the problem (as highlighted above), as well as the demands of DBT treatment for the disorder. DBT is an active form of treatment that requires the person with borderline personality disorder to do work outside of session. (Click here for more information about the nature of borderline personality disorder and dialectical behavior therapy.)

2. Develop Distress Tolerance Skills

Distress tolerance skills can help a person cope with sudden, overwhelming emotions in a healthier way so that the pain doesn’t lead to long-term suffering. Distraction techniques, like engaging in pleasurable activities or paying attention to someone else, can temporarily help a person stop thinking about something painful and therefore allow the person to choose a healthy way of coping. Self-soothing techniques, like taking a warm bath or listening to pleasant music, use the five senses to bring peace and relief from pain. With practice, visualization and relaxation techniques, like cue-controlled relaxation, can also quickly create a sensation of peace. Making committed actions and connecting with a sense of higher power can make life more fulfilling and meaningful. Radical acceptance is a very important distress tolerance skill that will help the people with borderline personality disorder reexamine painful situations so that they can stop fighting and judging painful situations that can’t be changed. (Click here for instructions on how to use distress tolerance skills.)

3. Develop Mindfulness Skills

Mindfulness skills can help people become more aware of their thoughts, emotions, physical sensations, and actions—in the present moment—without judging or criticizing themselves or their experiences.⁷² Mindfulness skills focus a person’s attention on what’s happening now, rather than painful memories of the past or anxious thoughts about the future. The core mindfulness skill is mindful breathing, which focuses attention on the rising and falling of the breath, rather than thoughts. Thought defusion is a technique that can help people learn to let go of those thoughts without becoming angered by them. Mindful emotion techniques allow people to shift focus between what they are feeling and what’s happening in the present moment. The wise mind technique can help people make healthier decisions about life based on rational thoughts and emotions. Doing what’s effective is a mindfulness skill that helps people solve problems in new ways. And, finally, meditation can be used to develop kindness and compassion for oneself and others. (Click here for instructions on how to use mindfulness skills.)

4. Develop Emotion Regulation Skills

Emotion regulation skills serve a number of different purposes. They help people identify their emotions more clearly and easily, and help them cope with painful emotions instead of getting overwhelmed by them. They can also help people reduce their vulnerability to overwhelming emotions, increase their experiences of positive emotions, and learn to be mindful of emotions without judging them. Emotion exposure techniques can help people learn not to fear their feelings. Learning to do the opposite of emotional urges blocks ineffective, emotion-driven responses to situations. And, finally, problem-solving skills can help people develop coping strategies for events that trigger difficult emotions. (Click here for instructions on how to use emotion regulation skills.)

5. Develop Interpersonal Regulation Skills

Interpersonal regulation skills help people with borderline personality disorder learn how to express their thoughts and feelings in effective ways that help them get their needs met. Mindful attention skills are useful for recognizing how others are feeling and creating more satisfying relationships. Assertive communication and listening skills are also powerful interpersonal tools. These skills can help people get their needs met, set limits with others, learn how to say no, and negotiate for what they want. (Click here for instructions on how to use interpersonal regulation skills.)

6. Prevent Relapse

Finally, the last step of the DBT treatment for borderline personality disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the DBT skills learned in treatment and to recognize the early signs of recurring distress, such as overwhelming fears of abandonment, in order to take steps to prevent relapse. (Click here for instructions on preventing relapse of borderline personality disorder.)

REFERENCES FOR BORDERLINE PERSONALITY DISORDER

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