BPD

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BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder (BPD) is one of the most

controversial diagnoses in psychology today. Since it was first

introduced in the DSM, psychologists and psychiatrists have been

trying to give the somewhat amorphous concepts behind BPD a

concrete form. Kernberg's explication of what he calls

Borderline Personality Organization is the most general, while

Gunderson, though a psychoanalyst, is considered by many to have

taken the most scientific approach to defining BPD. The

Diagnostic Interview for Borderlines and the DIB-Revised were

developed from research done by Gunderson, Kolb, and Zanarini.

Finally, there is the " official " DSM-IV definition.

Some researchers, like Judith Herman, believe that BPD is a name

given to a particular manifestation of post-traumatic stress

disorder: in Trauma and Recovery, she theorizes that when PTSD

takes a form that emphasizes heavily its elements of identity

and relationship disturbance, it gets called BPD; when the

somatic (body) elements are emphasized, it gets called hysteria,

and when the dissociative/deformation of consciousness elements

are the focus, it gets called DID/MPD. Others believe that the

term " borderline personality " has been so misunderstood and

misused that trying to refine it is pointless and suggest

instead simply scrapping the term.

What causes Borderline Personality Disorder?

It would be remiss to discuss BPD without including a comment

about Linehan's work. In contrast to the symptom list approaches

detailed below, Linehan has developed a comprehensive

sociobiological theory which appears to be borne out by the

successes found in controlled studies of her Dialectical

Behavioral Therapy.

Linehan theorizes that borderlines are born with an innate

biological tendency to react more intensely to lower levels of

stress than others and to take longer to recover. They peak

" higher " emotionally on less provocation and take longer coming

down. In addition, they were raised in environments in which

their beliefs about themselves and their environment were

continually devalued and invalidated. These factors combine to

create adults who are uncertain of the truth of their own

feelings and who are confronted by three basic dialectics they

have failed to master (and thus rush frantically from pole to

pole of):

* vulnerability vs invalidation

* active passivity (tendency to be passive when confronted

with a problem and actively seek a rescuer) vs apparent

competence (appearing to be capable when in reality

internally things are falling apart)

* unremitting crises vs inhibited grief.

DBT tries to teach clients to balance these by giving them

training in skills of mindfulness, interpersonal effectiveness,

distress tolerance, and emotional regulation.

Kernberg's Borderline Personality Organization

Diagnoses of BPO are based on three categories of criteria. The

first, and most important, category, comprises two signs:

* the absence of psychosis (i.e., the ability to perceive

reality accurately)

* impaired ego integration - a diffuse and internally

contradictory concept of self. Kernberg is quoted as saying,

" Borderlines can describe themselves for five hours without

your getting a realistic picture of what they're like. "

The second category is termed " nonspecific signs " and includes

such things as low anxiety tolerance, poor impulse control, and

an undeveloped or poor ability to enjoy work or hobbies in a

meaningful way.

Kernberg believes that borderlines are distinguished from

neurotics by the presence of " primitive defenses. " Chief among

these is splitting, in which a person or thing is seen as all

good or all bad. Note that something which is all good one day

can be all bad the next, which is related to another symptom:

borderlines have problems with object constancy in people --

they read each action of people in their lives as if there were

no prior context; they don't have a sense of continuity and

consistency about people and things in their lives. They have a

hard time experiencing an absent loved one as a loving presence

in their minds. They also have difficulty seeing all of the

actions taken by a person over a period of time as part of an

integrated whole, and tend instead to analyze individual actions

in an attempt to divine their individual meanings. People are

defined by how they lasted interacted with the borderline.

Other primitive defenses cited include magical thinking (beliefs

that thoughts can cause events), omnipotence, projection of

unpleasant characteristics in the self onto others and

projective identification, a process where the borderline tries

to elicit in others the feelings s/he is having. Kernberg also

includes as signs of BPO chaotic, extreme relationships with

others; an inability to retain the soothing memory of a loved

one; transient psychotic episodes; denial; and emotional

amnesia. About the last, Linehan says, " Borderline individuals

are so completely in each mood, they have great difficulty

conceptualizing, remembering what it's like to be in another mood. "

Gunderson's conception of BPD

Gunderson, a psychoanalyst, is respected by researchers in many

diverse areas of psychology and psychiatry. His focus tends to

be on the differential diagnosis of Borderline Personality

Disorder, and Cauwels gives Gunderson's criteria in order of

their importance:

* Intense unstable relationships in which the borderline

always ends up getting hurt. Gunderson admits that this symptom

is somewhat general, but considers it so central to BPD that he

says he would hesitate to diagnose a patient as BPD without its

presence.

* Repetitive self-destructive behavior, often designed to

prompt rescue.

* Chronic fear of abandonment and panic when forced to be alone.

* Distorted thoughts/perceptions, particularly in terms of

relationships and interactions with others.

* Hypersensitivity, meaning an unusual sensitivity to

nonverbal communication. Gunderson notes that this can be

confused with distortion if practitioners are not careful

(somewhat similar to Herman's statement that, while survivors of

intense long-term trauma may have unrealistic notions of the

power realities of the situation they were in, their notions are

likely to be closer to reality than the therapist might think).

* Impulsive behaviors that often embarrass the borderline later.

* Poor social adaptation: in a way, borderlines tend not to

know or understand the rules regarding performance in job and

academic settings.

The Diagnostic Interview for Borderlines, Revised

Gunderson and his colleague, Kolb, tried to make the

diagnosis of BPD by constructing a clinical interview to assess

borderline characteristics in patients. The DIB was revised in

1989 to sharpen its ability to differentiate between BPD and

other personality disorders. It considers symptoms that fall

under four main headings:

1. Affect

* chronic/major depression

* helplessness

* hopelessness

* worthlessness

* guilt

* anger (including frequent expressions of anger)

* anxiety

* loneliness

* boredom

* emptiness

2. Cognition

* odd thinking

* unusual perceptions

* nondelusional paranoia

* quasipsychosis

3. Impulse action patterns

* substance abuse/dependence

* sexual deviance

* manipulative suicide gestures

* other impulsive behaviors

4. Interpersonal relationships

* intolerance of aloneness

* abandonment, engulfment, annihilation fears

* counterdependency

* stormy relationships

* manipulativeness

* dependency

* devaluation

* masochism/sadism

* demandingness

* entitlement

The DIB-R is the most influential and best-known " test " for

diagnosing BPD. Use of it has led researchers to identify four

behavior patterns they consider peculiar to BPD: abandonment,

engulfment, annihilation fears; demandingness and entitlement;

treatment regressions; and ability to arouse inappropriately

close or hostile treatment relationships.

DSM-IV criteria

The DSM-IV gives these nine criteria; a diagnosis requires that

the subject present with at least five of these. In I Hate You

-- Don't Leave Me! Jerold Kriesman and Hal Straus refer to BPD

as " emotional hemophilia; [a borderline] lacks the clotting

mechanism needed to moderate his spurts of feeling. Stimulate a

passion, and the borderline emotionally bleeds to death. "

Traits involving emotions:

Quite frequently people with BPD have a very hard time

controlling their emotions. They may feel ruled by them. One

researcher (Marsha Linehan) said, " People with BPD are like

people with third degree burns over 90% of their bodies. Lacking

emotional skin, they feel agony at the slightest touch or movement. "

1. Shifts in mood lasting only a few hours.

2. Anger that is inappropriate, intense or uncontrollable.

Traits involving behavior:

3. Self-destructive acts, such as self-mutilation or suicidal

threats and gestures that happen more than once

4. Two potentially self-damaging impulsive behaviors. These

could include alcohol and other drug abuse, compulsive spending,

gambling, eating disorders, shoplifting, reckless driving,

compulsive sexual behavior.

Traits involving identity

5. Marked, persistent identity disturbance shown by uncertainty

in at least two areas. These areas can include self-image,

sexual orientation, career choice or other long-term goals,

friendships, values. People with BPD may not feel like they know

who they are, or what they think, or what their opinions are, or

what religion they should be. Instead, they may try to be what

they think other people want them to be. Someone with BPD said,

" I have a hard time figuring out my personality. I tend to be

whomever I'm with. "

6. Chronic feelings of emptiness or boredom. Someone with BPD

said, " I remember describing the feeling of having a deep hole

in my stomach. An emptiness that I didn't know how to fill. My

therapist told me that was from almost a " lack of a life " . The

more things you get into your life, the more relationships you

get involved in, all of that fills that hole. As a borderline, I

had no life. There were times when I couldn't stay in the same

room with other people. It almost felt like what I think a panic

attack would feel like. "

Traits involving relationships

7. Unstable, chaotic intense relationships characterized by

splitting (see below).

8. Frantic efforts to avoid real or imagined abandonment

* Splitting: the self and others are viewed as " all good " or

" all bad. " Someone with BPD said, " One day I would think my

doctor was the best and I loved her, but if she challenged

me in any way I hated her. There was no middle ground as in

like. In my world, people were either the best or the worst.

I couldn't understand the concept of middle ground. "

* Alternating clinging and distancing behaviors (I Hate You,

Don't Leave Me). Sometimes you want to be close to someone.

But when you get close it feels TOO close and you feel like

you have to get some space. This happens often.

* Great difficulty trusting people and themselves. Early trust

may have been shattered by people who were close to you.

* Sensitivity to criticism or rejection.

* Feeling of " needing " someone else to survive

* Heavy need for affection and reassurance

* Some people with BPD may have an unusually high degree of

interpersonal sensitivity, insight and empathy

9. Transient, stress-related paranoid ideation or severe

dissociative symptoms

This means feeling " out of it, " or not being able to remember

what you said or did. This mostly happens in times of severe stress.

Miscellaneous attributes of people with BPD:

* People with BPD are often bright, witty, funny, life of the

party.

* They may have problems with object constancy. When a person

leaves (even temporarily), they may have a problem

recreating or remembering feelings of love that were present

between themselves and the other. Often, BPD patients want

to keep something belonging to the loved one around during

separations.

* They frequently have difficulty tolerating aloneness, even

for short periods of time.

* Their lives may be a chaotic landscape of job losses,

interrupted educational pursuits, broken engagements,

hospitalizations.

* Many have a background of childhood physical, sexual, or

emotional abuse or physical/emotional neglect.

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