Borderline Personality Disorder
People with borderline personality disorder tend to see the world only in black and white, everything else is not recognized. People around them & with whom they are in relationship in are either extremely good & idealized or abysmally bad. Are you the devil or an angel? Borderlines often fluctuate between the extremes, a man she adored today may become “a bag of crap” tomorrow. Between idealized hot love & ice-cold hatred sometimes is just a wrong word or an imaginary, non-factual view. Thus, interpersonal relationships of those suffering with borderline personality disorder are generally unstable. Much of this is caused by their efforts to avoid imagined abandonment (“I hate you, do not leave me!”). This instability of perception refers not only to other people, but also to their own self-image. The very blurred picture of oneself, unrealistic and therefore unattainable goals often lead to self-depreciation. Severe mood swings are greatly triggered by the outside world.
BPD affects 2% of adults (20% of psychiatric hospitalizations, up to 10% outpatients), most of which are young women. Estimated suicide rates are 9-10% among those who suffer from this personalty disorder.
People with borderline personality disorder are often extremely impulsive, have very weak self-control. They waste money, likely to have verbal outbursts, have instable & excessive sexual needs, which often lead to sexual acts with dangerous or unwanted people & unprotected sex, abuse alcohol and other drugs, which in their turn endanger the safety of others through excessive recklessness, are prone to uncontrolled diet (excessive eating or no eating) and very likely to commit self harm (self cutting, for example, with knives or razor blades) and in some cases suicide. They are nearly as likely to commit suicide as those with major depression. It is particularly difficult for them to control their anger; the borderline anger can make dealing with a borderline patient a hell.
As with most mental disorders, the causes of the borderline personality disorder are still unclear. Various psychotherapeutic schools offer different explanations for these often strange behaviors. From a psychoanalytical point of view, the borderline syndrome is one of the so-called “early disturbances”. According to this theory, the development of borderline syndrome occurs within the first 18 to 36 month of life, a period during which the child learns to distinguish between self and other people or objects. The main causes by this group of psychoanalytics are considered the experience of painful separation, neglect, other significant trauma, like sexual abuse, physical abuse or emotional cruelty. Behavior therapist Marsha Linehan is one of the leading experts of borderline personality disorder. She developed the so-called dialectical behavior therapy, originally used to treat hospitalized suicidal borderline-ill women. In their view, borderline syndrome is a disorder that affects mostly emotionally vulnerable people, who grow up in a devaluing environment, and emotionally vulnerable people react excessively to stress. This environment is generally created by caregivers, the emotional expressions of the child is not accepted as are, the true expression of the mood is not acceptable & not welcome, as well as achievements are devalued; such environment serves as a base for most of the problems and seeds lack of motivation for the child. Very often only the negative traits & attributes are seen in the child and every failure is seen as a confirmation of these attributes.
Studies on people with borderline personality disorder consistently show that these patients mainly come from families with disturbed bonds & usually have family members or close relatives suffering from mental disorders. The frequently voiced hypothesis that female borderline patients as a rule were sexually abused could not be confirmed by research (Salzman, JP and others, 1997). Sexual abuse is neither necessary nor sufficient to cause a borderline personality disorder. Recent neurobiological research indicates that borderline personality disorder is associated with brain disorders. BPD is currently best classified in terms of dimensions rather than as a categorical disorder. The 2 core dimensions are affective disregulation and impulsivity. Most of the neuropsychologic, physiologic, endocrinologic, and neuroimaging data support that a dual brain pathology, affecting prefrontal and limbic circuits, is responsible for the over-stimulation and the emotional loss of control (Bohus, M., Christian Schmahl and Klaus Lieb).
The treatment of borderline personality disorder is considered extremely difficult and demanding. Therapeutic approach for each case must be different, a primary focus are those borderline personality characteristics of patients that cause a direct threat to life & well-being. These include the high impulsivity and suicide risk of those affected.
People with borderline personality disorder, as already described, tend to be jumping between extremes. A therapy developed by Marsha Linehan is trying to find a middle ground between these extremes. The American psychotherapist calls it “dialectical behavior therapy”. Dialectic is based on an argument/dialog between parties with different views, while applying reality & reason, trying to find the truth through exchanging their viewpoints. Dialectical behavior therapist engages in a dialog with the patient and challenges him/her for the purpose of providing the patient with effective problem solving techniques and to develop a tendency for the patient to validate themselves/their actions/emotions/conclusions against reality.
The therapy is divided into sections:
The preparatory phase focuses on psycho-diagnostics, gathering more information about the patient, as well as informing the patient about the form of therapy, and motivating the patient for treatment.
Stage 1 of therapy focuses on suicidal tendencies, self-harming behaviors and behaviors that drastically impact the quality of life. It also includes addressing the resistance against therapy.
Stage 2 deals with the effects of psychological trauma in childhood.
Stage 3 deals with self-respect & self-esteem and finally unique issues for the particular patient. The raise of self-esteem, ability of evaluation and problem solving are the guiding principles of the treatment.
The psychoanalyst Otto F. Kernberg (1988) practiced a modified form of psychoanalysis for the treatment of people with borderline personality disorder. It’s called Transference-Focused Psychotherapy. Transference Focused Psychotherapy was based upon Menninger Foundation’s psychotherapy research project, which stated that the optimal treatment of patients with severe personality disorders was a psychoanalytic psychotherapy, with systematic interpretation of the transference in the hours, as well as the provision of as much external support outside the hours to permit the treatment to develop successfully. In constant neither of the two separately was as affective (Kernberg, Paul Williams). The patients are thought to be experiencing so-called ‘splits’ (black & white) in their experience of feeling, emotion and thinking. Opinions are strong, but not stable. This “split” determines the way patient evaluates others and the environment and is literally a primitive defense mechanism against aggressive stressors. Individuals with BPO (Borderline Personality Organization) may lack tactfulness in social interactions, especially under stress. For instance, under stress those with BPO easily regress to paranoid thinking (John F. Clarkin, Frank E. Yeomans, Otto F. Kernberg). The objective of the treatment is integrating the split parts and object representations. Basically, the therapist finds the shared reality with the patient & slowly shifts the patient towards the objective reality. The therapist takes a position of technical neutrality, clarifying what’s in patients mind, rather than clarifying the information to her/him.
Other psychotherapists believe that psychoanalytic interpretation of borderline patients leads to worsening of their condition. They believe that although the therapist must explore his patient, but help with non-analytical methods to better adapt to reality. In this case, the therapist does not work & help understand the unconscious processes of the individual, but instead talks about the obvious defense operations and impact of the borderline personality disorder patient’s current actions on his/her life.