Borderline Personality Disorder
Joanna Tepedino
Abnormal Pyschology

Borderline personality disorder is the most prevalent personality disorder found in mental health facilities. BPD lies within the group B personality disorders, Axis II of the DSM IV, a manual used by psychiatrists to diagnose and define mental health diseases, and is characterized by dramatic, emotional and erratic personality features that are mood inflicted and have symptoms of impulsively and emotional degradation (Australian Psychological Society 22). A person displaying symptoms of BPD must present with at least five of the nine criteria for diagnosis for a period of time before reaching adulthood: frantic efforts to avoid real or imagined abandonment, unstable/intense interpersonal relationships, unstable issues with self-image/sense of self, impulsivity in at least two areas that cause harm to oneself, recurrent suicidal tendencies/attempts or self-mutilation, affective instability due to mood, chronic feelings of emptiness or worthlessness, inappropriate anger and last transient, stress-related paranoid ideation or severe dissociation (Counseling Psychology Review).

Individuals suffer from different personality traits, which can become maladaptive, volatile, unchanging and extreme which hinder a person in their ability to function in every day life. This rigidity prevents people from adjusting to external demands thus the patterns become self-defeating and this is known as a personality disorder (book). The term borderline personality disorder originated in the 1930’s by clinical observations of Adolph Stern who recognized a subgroup of patients that didn’t fit into the existing system mainly consisting of a diagnosis of neuroses and psychoses, dubbing the term “borderline” (Austrailan). Today the disorder is characterized by abrupt problems of shifts in mood, unpredictable and impulsive behavior and lack of a coherent sense of self all leading the borderline individual to prevent having interpersonal relationships.

People with borderline personality disorder tend to have uncertainties about their personal identity leading them to have very intense and unstable personal relationships. The identity issues extend into almost every aspect of their lives including questions on goals, careers, values and sexual orientation. Individual’s feelings towards others are constantly shifting from extreme adulation to extreme loathing, which means they do not simply come in and out of friendships easily but instead have dramatic changes in relationships. This fluctuation in self-identity leaves the borderline with thoughts of paranoia about feelings of emptiness and abandonment by others. This fear renders the borderline to be clingy and demanding in social situations, which then pushes others away straining their relationships further causing anger and thought disturbances.

Borderlines have difficulty regulating their mood. Its not considered manic, like bipolars but alternates between a mild to moderate level of depression (Livesley). Their moods run from anger and irritability to depression and anxiety shifting frequently and abruptly. The anger they experience interferes with social functioning which alienates people causing them to have violent outburst and are prone to fighting and smashing things. Recent research has shown that medications can significantly relieve the suffering of borderline patients when used in combination with psychotherapy (Livesley).

"The instability of mood, thoughts, interpersonal relationships and behavior that is characteristic of the borderline personality disorder has led some theorists to believe that individuals with this disorder have a problem with identity" (Holmes 222). Identity is "the individual self" (Chaplin 218). That is, the instability reflects the lack of any real sense of self or self-direction, and indeed these individuals report a feeling of emptiness (Durand 144).

Individuals with BPD are impulse driven involving self-destructive behaviors including self-mutilation and suicidal behavior. Women are more prone to inward directed aggression including cutting or self-mutilation with help of a razor blade or fingernails. This behavior does not seem to want to result in death but self-mutilation is often done to feel or experience themselves as real, its an act to feel numb particularity during high times of stress. This stress stems from emotional instability, mood changes and high anxiety, sadness, depression and feelings of emptiness which all lead to acute psychotic episodes or suicide attempts.

Since BPD is such a severe form of a personality disorder those affected make up a large portion of patients in mental health facilities constituting 1-2% of American adults, 10% of psychiatric outpatients and 15-20% of psychiatric inpatients. An astounding 69-80% of patients with BPD engage in suicidal behavior (including suicide attempts and life-threatening actions), and up to 9% of patients with BPD die by suicide (Harvard). The current thinking of BPD is that it develops due to multiple factors such as trauma in childhood.

The aetiology of BPD is conflicting theory between biological basis and biological irregularities and environmental experiences. The biological basis is supported by the indications that erratic mood swings, social cognitive difficulties and maladaptive behaviors may be caused by prefrontal and temporolimbic dysfunction. There is also a link between low serotonin levels and impulsiveness and aggression to borderline personality disorder (Mental Health Practice).
The environmental aspect attributing to borderline personality disorder stems from an inconsistency between a child’s private internal world and reality, this includes painful experiences, punishment without acknowledgment of a wrongful deed and not recognizing a child’s needs. This leads to children not gaining the coping skills to tolerate stress, control their emotions and trust themselves, which teaches maladaptive behaviors. Physical and sexual abuse was reported in about 25% of inpatients. The negative consequences of early abuse include a lack of empathy, desensitization, deep mistrust of caregivers and a lack of responsiveness of others (Mental Health Practice).

To help reduce symptoms of borderline personality disorder clinical data and APA guidelines show that a combination of medication and therapy will significantly lower symptoms of depression, anxiety, irritability and paranoid thoughts. The treatment of BPD for a therapy session varies among disciplines of psychiatry. To date, different models of psychotherapy have been tested for BPD in single or combined therapy studies. Recent research studies have demonstrated the effectiveness of individual cognitive behavioral therapy along with group psychoeducation and skills training that teach emotional regulation skills, distress tolerance, improved interpersonal relationship behaviors and awareness (mindfulness); This, combined with careful medication management, may allow the patient to achieve significant progress (Harvard). The most extensive research has been done with psychodynamic psychotherapy, dialectical behavior therapy, cognitive therapy and IPT. IPT was initially used to treat major depression, but it has successfully been extended to other psychiatric disorders. Features of IPT involve a three part treatment plan: different conceptualization of the disorder, a prolonged length of treatment (first acute phase of 18 IPT sessions and a continuation phase of 16 sessions, up to 34 IPT sessions over 8 months), flexibility of setting (a 10-minute telephone contact once a week is provided) to handle crises and minimize the risk of therapeutic ruptures (Canadian).

This original research study was performed using IPT on patients with BPD and without concomitant Axis I disorders, comparing combined treatment with fluoxetine, a selective serotonergic reuptake inhibitor. Patients were randomly divided into 1 of 2 treatment cells: pharmacotherapy or combined therapy. Only patients with Axis II BPD disorders were included, no concomitant diagnoses. Also patients who were of childbearing age and not on birth control and patients who had received psychotropic drugs in the last 2 months were excluded. Both treatments were started at the same time and would last 32 weeks. Psychiatrists evaluated the patients with BPD based on different psychological scales and models to determine which treatment was more effective.