Living on the Borderline
Borderline Personality Disorder affects more than 2 million adults in the United States. It is more common than schizophrenia or bi-polar disorder and has a suicide rate of nearly 10%. It was previously thought that Borderline personalities were incurable and rather than try to treat patients who were manipulative, angry and not making progress, psychiatrists turned them away. In the past twenty years, however, new therapeutic approaches to treating and interacting with Borderline patients have increased the number of people who can lead healthy lives with fewer episodes of psychosis and depression.
Borderline personalities are distinguished by a number of traits. The condition is marked by an intense and all consuming fear of abandonment. The diagnostic criteria for BPD include: Frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation, identity disturbance, self destructive and impulsive behavior.(1)
As someone who has lived in a household with a parent who exhibits many of these borderline traits, I can testify to the seemingly impossible nature of borderline personalities. It is a condition that eats away at everyone around the affected person because they constantly lash out. Splitting, the process of seeing someone or something as all good or all bad, is a trademark of BPD, and it is one of the characteristics that make it such a hard condition to treat. For instance, if someone with BPD sees a therapist as all good one day and all bad the next, it may have an effect on their willingness to come to, participate or advance in therapy.
Koenigsberg et.al attribute this splitting to the lack of a basic development in borderlines as infants.(2) A very young infant is incapable of seeing others as more than unidimensional entities and so splits their parents into good or bad depending on the act they are performing. Either they are providing or taking away. It is only at a certain point that infants can integrate the good and bad of one person into a single identity. Borderlines carry this tendency to split into adulthood, and although it is most obvious to members of their immediate family, a Borderline's splitting tendency is often visible in the bursts of passionate friendship they share with others. The moment a friend or loved one does not fit into the strictly good category, they are switched to the bad(3).
Borderlines often abuse substances or mutilate themselves. Koenigsberg attributes some of their self-injurious behavior as a method of coping with their violent outbursts. Driven by a fear of being alone, many Borderlines will resort to manipulation and fear to prevent others from leaving. When they are conscious of what they have done, they see themselves as all bad and punish themselves. The laws of splitting apply to Borderlines themselves, and so when they feel depressed, they may loathe themselves. However, when they are in another emotional state, they may see themselves as perpetually right.
BPD is a condition that most likely develops out of a combination of childhood abuse, neglect, and hereditary predisposition. (4).Over eighty percent of Borderline patients report childhood abuse and neglect, and individuals whose parents suffered from BPD are more at risk to develop BPD themselves. I think, however, that this is not as much evidence for the hereditary nature of the condition as much as logical continuation of abuse. Many parents with BPD are either physically or emotionally abusive to their children, and so the children of borderline parents are already at risk due to environmental factors.
Treatment plans for people with BPD have varied over the years. The cluster of symptoms associated with BPD was not -and in some circles is still not- recognized by the psychiatric community for years. BPD was misdiagnosed as schizophrenia, bi-polar disorder and a slew of other illnesses but the patients persistently did not respond well to treatment. Yoemans and Selzer maintain that the only way to ensure treatment of a borderline patient is to work with a therapy contract designed by both the patient and the doctor that outlines what the behaviors of both parties will be should crises arise(5). Due to the subtle manipulation and great intelligence present in Borderline patients, it is often difficult for a psychiatrist to establish control in the doctor/patient relationship. A contract based method of treatment is a way for the the therapist to catch themselves if they feel as if they are losing control. As much as they might fight against it, Borderlines respond positively to external structure. Many of their symptoms are brought about by the loss of of structure, and giving them a framework in which to recover and heal is one of the best things a doctor can provide.
Borderline Personality Disorder is a very difficult condition to treat because its symptoms render the person affected completely unpleasant. Borderlines can be some of the most demanding cases for a psychiatrist, but with new technology, medication and understanding of mental health, it is possible for them to live relatively normal, stable lives without being in a state of constant fear and self loathing.
1) Krawitz, Roy and Watson, Christine. Borderline Personality Disorder: A Practical Guide to Treatment. NY, Oxford University Press, 2003
2) Koenigsberg, Harold W., Kernberg, Otto F., Stone, Michael H. Applebaum, Ann H, Yoemans, Frank E. Diamond, Diana. Borderline Patients: Extending the Limits of treatability. NY. BasicBooks. 2000
(5) Yoemans, Frank E, Selzer, Michael A, Clarkin, John F. Treating the Borderline Patient: a Contract Based Approach, NY, Basicbooks, 1992