Borderline Personality Disorder

The borderline patient is what makes most psychiatrists/therapists cringe, because nothing is ever easy with them.  Of all the patients I can think of, they are without a doubt the most difficult and at times plain unmanageable to treat.   Anytime I have gone to psychiatric conferences, just the mention of borderline congers up snickers in the audience, and for good reason.

Borderline personality disorder is one of  the ten personalities disorders as listed in the DSM-IV.   You can not label all difficult people as borderline, because there are certain criteria in order to be diagnosed.   The behaviors that I will describe are pervasive rather than occasional.  You can start to see the intensity of their symptoms in adolescence or in early 20’s.

The major psychological cause that I find consistent with these types of patients is abuse and poor mothering .  Often their mothers have borderline tendencies themselves, and the major deficit is early emotional abandonment and or neglect.  Their mothers usually displays little consistency of love and attention, with disregard of the child’s needs.

Borderline mothers withdraw love if the child does not do as they want or expect, and will only provide love if the child conforms to their will, not allowing any leeway.  The child can integrate this as splitting into either all conforming to her will provide love, and not as being bad , resulting in being emotionally abandoned.

All abuse, be it emotional, physical of sexual  can cause later mood disturbance as an adult to various degrees.  Genetically, if one has inherited a tendency toward mood disorders then that plus abuse can lead towards developing a borderline personality.

So what is this personality disorder that no ones wants in their practice?   I will describe the various behaviors that one sees in borderline patients.   Most initially come across as extremely charismatic, and are usually very engaging with much emotional intensity.  They offer rich emotional displays which depicts themselves usually as  distraught victims.    They come across as  histrionic in all avenues of their life.

Their history if chock full of intense chaotic relationships, usually ruined by their impulsive and explosive anger.  Their anger can come without provocation and without warning, so having a relationship with a borderline personality is like a roller coaster in hell.   They take very quick offense for things that others would not even be bothered.   Their rational for being angry is self-serving and can even seem imaginary.

They have a very labile mood, which means they are very moody, given to depressive lows and irritability.    Their mood lability can mimic that of someone in the bipolar spectrum.  They are impulsive and often have a past of substance abuse or eating disorder.

They are also inveterate manipulators, who seemingly have perfect timing to attempting to get something their way.  They have grown up doing this so it becomes very ingrained behavior with them to extent they rarely see the manipulation within themselves.

They are prone to use suicidal threats also in a manipulative way . Usually their psychiatric histories are peppered with suicidal gestures, the majority non life threatening, but can also have serious ones too.  All suicidal threats need to be considered serious until proven otherwise with them.

Beside the suicidal threats posing a danger, a lot of them are self mutilators.  If you have never seen this sort of behavior, it is hard to comprehend.  Most cut themselves , but some will burn their skin, or peel their nail to cause bleeding.   Obviously they have to hide this from family and friends, with clothing, but scaring is a dead giveaway.

The vast majority of self mutilators have a history of sever emotional, sexual or physical abuse in their childhoods.  The pain they have numbed out in their psyche is recreated with the cutting and burning that they can feel, and it does provide a sense of psychic release, however maladaptive it is.

A very prominent characteristic is splitting , which is a Freudian term for seeing things either black or white.  These patients can not see any grey so to speak in human behavior.  This leads to overidealization or under devaluation .  They can love you to death one minute, then find fault with you the next.

Therapists have to handle them with kid gloves because of the above, but  they are the type that would have found fault with Mother Theresa.  Therefore there is quite a bit of countertransference issues with these patients, making therapy difficult.  On a very few occasions I have had to refer them away due to their explosive anger and manipulation.

They also have an insatiable need for attention and immediacy, with little tolerance for any deviation or being alone, due to their unstable self-image.   They have unrealistic expectations of all, including therapists to be always available to their beck and call.  Calls at inappropriate times often occur.  They are given to feelings of emptiness and boredom.

In hospital settings they will pit one staff member against another and will do  the same in psychotherapy groups.  I have seen them tear up groups with their manipulative pitting, explosive anger and vacillating loyalties.  Therefore their presence makes for fireworks, and I prefer that they are not included except with other borderlines, but pity the poor therapist in charge!

Psychotherapy focuses of treating the mood symptoms first, especially when there is depression, which is often the case.  Getting the borderline patients to look at their very maladaptive ways of behavior is difficult and slow.  They will often exit therapy for a while and then come back.  They react to the therapist basically the same as they do others in their life, so it is never an easy ride.

The bottom line, is that you can not change people’s personality, but with therapy some are able to modify some of their destructive behavior.  The prognosis is guarded at best for full-blown borderlines, but in treating at least the mood liability or depression, they can be easier to get along and live with.

Family or conjoint therapy is always needed but again very difficult because of the destructive traits.   Being married to a borderline is exhaustive in trying to placate and meet their needs, and eventually the partner often gives up and leaves to preserve their own sanity and peace.