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Borderline personality disorder is characterized by a pattern of intense, unstable, interpersonal relationships. This intensity and instability is one of the hallmarks of the disorder and one of the most discriminating features. Borderline individuals often have intense and persistent anger. They can be quite ragefull and demanding and they struggle with intense dependent longings and also hostility toward the people on whom they are dependent. So actually there was a book a few years ago about borderline personality disorder.
Borderline personality disorder individuals are very adept at blackmailing other people to do their bidding and many of you are quite familiar with this; the patient who is about to leave at the end of a Friday afternoon session and puts a hand on the doorknob and says, "Oh, by the way. I have a stash of pills and I think I’ll probably kill myself so I won’t see you next week." Many borderline individuals are overwhelmed by anger.
They have low frustration tolerance. And often it is the overflow affect that prompts impulsive activity. Repeated self-destructive acts are the other most discriminating feature of the borderline disorder. So intense unstable relationships and repeated self-destructive acts are really the most discriminating diagnostic features. The self-destructive acts include wrist slashing, overdosing, car crashes, drug use, sexual promiscuity, abrupt changes in jobs. Often these are people who look quite good on interviews for jobs but then cannot sustain functioning in an ongoing way. Identity disturbance is a hallmark of the disorder and identity can be seen in a variety of areas in this disturbance: gender identity, personal goals, the difference between ones own and other people’s feelings, self-image, body image.
The defenses that are typically used are projection, projected identification, splitting and denial. Much of that in order to make the inner world safe by making the outer world unsafe and also idealizing individuals in order to see them as safe havens in what is otherwise a chaotic world for borderline individuals.
The diagnostic criteria are characterized by instability of interpersonal relationships and self-image. In terms of the etiology, much of the work on the etiology of borderline personality disorder has been done within the realm of psychoanalysis. Many theorists focus on the time in childhood between the age of six months and two years when the child is learning to separate from the mother. It was once thought that it is basically disturbances in this separation and individuation phase, of the child wanting to move away from the mother and then know that there is a safe haven to come back to. It is disturbances in that process that engender this intense hostile dependency and these fears of abandonment. In fact, J.T. Masterson was quoted as saying, "The mother of every borderline is herself a borderline." What he is trying to get at was the idea that there is a sense of autonomous function as being toxic and leading to abandonment that many of these people.
A genetic relationship to schizophrenia or to other axis I disorders has not been demonstrated, but there is certainly tremendous overlap between borderline personality disorder and affective disorders, so there is quite a bit of research trying to understand whether there may be biological bases.
In terms of epidemiology, the prevalence is thought to be between 2-4% of the population. Borderline individuals constitute 15-25% of psychiatric patients, both inpatient and outpatient. They are responsible for 10-20% of hospital admissions. Women are diagnosed twice as often as men, but that is probably due to cultural biases in that some of the more recent studies have shown that the ratio should be more like 60/40, 60% women to 40% men.
Course and prognosis. Many of the features of borderline personality disorder are also normal features of adolescence, so it is important not to diagnose - well, any personality disorder, but particularly borderline personality disorder - before the age of 16 and often we are skeptical before the age of 18, for example. It is most commonly diagnosed first in older adolescents.
In terms of differential diagnoses, I’ve talked about the other personality disorders that one would try to distinguish the borderline disorder from, but again, remember it is the unstable intense relationships and the chronic self-destructive and impulsive acts that taken together often point to borderline personality disorder in particular. Affective disorders are quite common. The overlap between affective disorders and borderline personality disorder is thought to be at least 50%.
Treatment then must involve treatment of affective disorders as well as treatment of the borderline disorder so that one cannot simply treat the symptoms of borderline personality without addressing affective disorders. Also, when we treat the affective disorder someone will often look much less dysfunctional in terms of their personality functioning. This is easier now that the antidepressants that we have are not so easy to overdose on. Using the SSRI’s is much more reassuring to the clinician than using the MAOI’s or tricyclics with these people who are prone to impulsive overdoses. Treatment is quite difficult. Usually the treatment is some form of psychodynamic or behavior therapy, or a combination of the two. The hallmark of therapy is creating a structured environment where borderline individuals boundary violations can be addressed within the treatment and where the therapist can help the patient connect the feelings with actions. Because one of the profound disconnects for borderline individuals is between what they feel and how they act. Often borderline individuals will not know that their actions are motivated by intense feeling.
There are some people who recommend exploratory psychotherapy that focuses on the past but I think most people now recognize that even in psychodynamically oriented exploratory therapy the exploration needs to be first and foremost on what’s going on in the here and now. So that the therapy focuses on self-destructive activities outside of the treatment, ways of undermining the treatment and only when those things are under control, only when brush-fires have been put out in the patient’s current life do you allow for the kind of exploration of the childhood that many borderline individuals.