Borderline Personality Disorder

The term borderline was originally coined by American psychologist Adolph Stern in 1938 to describe patients who live on the border between psychosis and neurosis. By 1967, Otto Kernberg elaborated borderline personality disorder (BPL) to include patients with impaired object relations; these patients used the primitive defenses of denial or splitting. Their sense of self was tenuous. They felt intense rage, often at being misunderstood, and their feelings were hard to inhibit.

Borderline individuals have a history of unstable interpersonal relationships. Because they have trouble seeing shades of gray in the world, they view significant people in their lives as either flawless or unfair and uncaring (a phenomena known as splitting). These alternating feelings of idealization and devaluation are the hallmark feature of borderline personality disorder. The person with BPL, according to Dan Buie and Gerald Adler, is uniquely tormented by a feeling of aloneness. Distinct from loneliness, this feeling is similar to a sense of identity fragmentation. The person with BPL feels like a child whose mother is out of sight and who does not remember that she still exists in the adjacent room. The diagnosis is typically associated with people who have had long-term trauma, intense feelings of abandonment, self-harm, and are terrified of being alone. Because borderline patients set up excessive and unrealistic expectations for others, they are frequently disappointed and enraged.

This diagnosis first appeared as a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders in the 1980s; after that the diagnosis attracted controversy. Some psychologists believe it does not exist and is a way of stereotyping women. Others, by contrast, believe it belongs on Axis I (as Stern first observed it) as a psychotic disorder and not on Axis II as a personality disorder. Some have argued that people with BPL actually have bipolar II or chronic post-traumatic stress disorder (PTSD). Other psychologists claim that it is used to label patients who are difficult to treat.

According to many sources, including the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness (NAMI), borderline personality disorder affects approximately 1% to 8% of the population. According to data from the NIMH-funded National Comorbidity Survey Replication, about 85% of people with borderline personality disorder also meet the diagnostic criteria for another mental disorder:

Suicide, one of the most tragic outcomes for any mental disorder, presents an especially high risk in this population. As many as 80% of people with borderline personality disorder have suicidal behaviors, and about 4% to 9% complete suicide.

As of 2015, statistics also implied that BPD seems more prevalent in Caucasian women than any other population. This data may be partly due to the fact that women are more likely to report for mental health services, whereas men may be more reluctant or resistant to do so. Adults with borderline personalities often have a history of significant traumas such as emotional and physical abuse, neglect, or the loss of a parent in childhood. Feelings of inadequacy and self-loathing that arise from these situations may be instrumental in developing a borderline personality. Some psychologists theorize that these patients try to gain the care they were denied in childhood through the idealized demands they make on themselves and on others in adult life.

Borderline personality disorder typically first appears in early adulthood. Although the disorder may occur in adolescence, it is difficult to diagnose at that time. Borderline symptoms, such as impulsive and experimental behaviors, insecurity, and mood swings are developmentally appropriate events for teenagers. Borderline symptoms may also appear as the result of substance abuse and/ or biologically based medical conditions. These causes must be ruled out before making the diagnosis of borderline personality disorder. Borderline personality disorder commonly co-occurs with mood disorders (i.e., depression and anxiety), post-traumatic stress disorder, eating disorders, attention deficit/hyperactivity disorder (ADHD), and other personality disorders.

Providing effective therapy for the borderline personality patient is a necessary but difficult challenge. The therapist-patient relationship is subject to the same unrealistic demands that borderline personalities place on all their significant interpersonal relationships. They are often chronic treatment seekers who become easily frustrated with their therapist if they feel they are not receiving adequate attention or empathy. Intense anger, impulsivity, and self-destructive behavior can impede the therapist-patient relationship. Fear of abandonment may actually cause the patient to discontinue treatment once progress is made.

Psychotherapy, typically a form of cognitive behavioral therapy, is often the best treatment for this disorder. Dialectical behavior therapy (DBT), a cognitive behavioral technique, has emerged as the most effective therapy for borderline personalities with suicidal tendencies. The treatment focuses on giving the borderline patient self-confidence and coping tools for life outside therapy. DBT offers social skill training, mood awareness, meditative exercises, and education on the disorder. Group therapy can be helpful for some borderline patients; others may feel threatened by the idea of sharing a therapist with others.

Medication is not a simple treatment choice, but it may be useful in treating symptoms of BPL and in alleviating the mood disorders that have been diagnosed in conjunction with it. Approximately 75% to 80% of borderline patients attempt or threaten suicide. If a borderline patient suffers from depressive disorder, the risk of suicide is much higher. For this reason, swift diagnosis and appropriate interventions are critical.

See also Dissociation/Dissociative disorders.