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Borderline Personality Disorder

A client with borderline personality disorder usually consists of a host of negative characteristics.  BPD is defined as "a pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts, "(American Psychiatric Association, 2000).  Patients who have borderline personality disorder usually display destructive behaviors and addictive behaviors, including self-mutilation. These actions are a cry for help, they expect someone to come save them or show that they care. They are also known continually to blame and criticize people.  The criticism often crosses the line into emotional or physical abuse.  Lacking a clear sense of whom they are and feeling empty, people with BPD feel lonely and in excruciating pain. So they may cope by denying their own unpleasant traits, behaviors, and feelings by attributing them to someone else. Patients with this disorder often attempt suicide and about 10 percent of them succeed(Oldham, 2006).  These behaviors can date back as early as adolescence, and can occur throughout the lifetime of a patient.  Patients can also show oral and addictive behaviors, which may include: drug abuse, obesity, anorexia, and bulimia.

Not only is the patient affected when borderline personality disorder is involved but the people around him or her as well can be dramatically overwhelmed.  Clients generally show a pattern of interactions with others that is characterized by clinging and distancing behaviors.  People who know people with this disorder often feel manipulated and lied to.  This may be the result of borderline personalities trying to get what they want through the only way they know how - emotional blackmail.  People with this disorder usually see people as wonderful or evil, this is an ego defense mechanism they have known as splitting.  For instance, a therapist can be seen as being very helpful and caring toward the client, but if some sort of difficulty arises in the therapy, or in the patient's life, the person might then begin characterizing the therapist as "bad" and not caring about the client at all.  Therapists and doctors should learn to be like a "rock" when dealing with a person with BPD(Sansone & Sansone, 1991).  Many professionals are turned-off by working with people with borderline personality disorder, because the client can bring such negative feelings.  These occur because of the clients constant demand on a clinician, the constant suicidal gestures, thoughts and behaviors, and the possibility of self-mutilating behavior.  The client may also detain the physician from others by keeping him or her in the examining room for the fear of abandonment and inability to be alone.  These situations are sometimes very difficult for a therapist to work with and understand.

Comorbidity is common in patients that have borderline personality disorder, because of their wide range of symptoms.  They have been linked to many different disorders including: mood and anxiety disorders, post traumatic stress disorder (PTSD), gender identity disorder, multiple personality disorder, attention deficit disorder, obsessive-compulsive disorder, eating disorders, and substance abuse(Paris, 2005).  While people with depression bipolar disorders typically endure the same mood for weeks, a person with BPD may experience anxiety, depression and anger for only hours or at most a day.  Patients with BPD are more likely to report histories of adult physical and sexual abuse and to meet diagnostic criteria for post traumatic stress disorder and eating disorders.  BPDs often use alcohol and other drugs in a chaotic and unpredictable pattern.  They often abuse benzodiazepines prescribed to them for anxiety(Frankenburg, Hennen, Reich, Silk, & Zanarini, 2004). 

Borderline personality disorder has been considered the most intense personality disorder, evoking intense hatred, images of rage, and negative emotion.  The frequency in women is three times greater than in men.  This may be related to genetic or hormonal influences.  Also, women commonly suffer from depression more often than men.  The increased frequency of borderline disorders among women may be a consequence of the greater incidence of incestuous experiences during their childhood, which occurs ten times more in women.  This chronic or periodic victimization can later result in impaired relationships and mistrust in men and excessive preoccupation with sexuality, sexual promiscuity, inhabitations, depression and a serious damaged self-image(Langley, Links & Vijay).  People with borderline personalities have been connected with emotional instability, impulsivity, and anxiety, which all have similar genetic components.  Central neurotransmitter activity shows that impulsive traits are linked with a shortage in central serotongic functioning.  Parents of individuals with this disorder are often vulnerable themselves to mood and personality disorders.  Their children become involved in cycles of anger and rejection.  Also, borderline personality disorders may be characterized by a variety of childhood psychopathology(Oldham, 2006).  Children and adolescents are involved in many different developmental stages in which their body and personality are changing at distinct times.  These changes create different relationships between friends and family.  It also has been reported that personality disorders in adolescents peak at age twelve in boys and age thirteen in Girls(Townsend, 2003).  

The course of borderline personality disorder varies.  While it is difficult for anyone to change major aspects of their personality, the symptoms of this disorder can be reduced in both number and intensity. There is mainly chronic instability in early adulthood.  Impairment and risks of suicides are most common in the younger clients and gradually improve(Kaplan, Sadock & Sadock, 2000).  Long term treatment is usually required for people with BPD.  Most people with this disorder improve over time with treatment. 

Borderline personality disorder is poorly understood and very controversial in young adults and children.  Often when they are young they require brief psychiatric hospitalization, followed by a variety of outpatient psychiatric treatments.  Every patient needs to be evaluated to get the treatment that is right for him or her.  The main thing for treating a child or teenager with BPD is to provide a safe environment in which they can continue education, address their specific problems and improve family functioning(Barlow & Durand, 2005).  Treatment for BPD has improved over the years. Like with most personality disorders, psychotherapy is the treatment of choice in helping people overcome this problem.  While medication can usually help some symptoms of the disorder, they cannot help the patient learn new coping skills, emotion regulation, or any of the other important changes in a person' s life.  An important aspect of psychotherapy is usually contracting with the person to ensure that they do not commit suicide.  Suicidality should be carefully assessed and monitored throughout treatment.  If suicidal feelings are strong, medication and hospitalization should be seriously considered. The most successful and effective psychotherapeutic approach to date has been dialectical behavior therapy.  It is based on negotiation between therapist and patient.  The therapist accepts and validates the patient the way he or she is, and while insisting on the need for change.  The idea  is to give the patient tools that he or she never found as a child, mainly control and how to deal with his or her emotions(Barrachina, Campins, Pascual, & Soler, 2005).  Antidepressants and anti-anxiety agents may be appropriate during particular times in the patient's treatment.  For example, if a client presents with severe suicidal ideation and intent, the clinician may want seriously to consider the prescription of an appropriate antidepressant medication to help combat the ideation.  Medication of this type should be avoided for long-term use, though since most anxiety and depression is directly related to short-term, situational factors that will quickly come and go in the individual's life.  The medical professions often overlook self-help methods for the treatment of this disorder because very few professionals are involved in them.  Encouraging the individual with borderline personality disorder to gain addition social support, however, is an important aspect of treatment.  Many support groups exist in communities throughout the world devoted to helping individuals with this disorder share common experiences and feelings(Barlow, 2005).  Patients can be encouraged to try new coping skills and emotion regulation with people they meet within support groups.  They can be an important part of expanding the individual's skill set and develop new, healthier social relationship. 
  

References
 American Psychiatric Association.  (2000).  Diagnostic and Statistical Manual of Mental Disorders.  (4th ed.). Washington, DC.              Barlow, D.  H., and Durand, M.  V.  (2005).  Abnormal Psychology: An Integrative Approach.  Belmont, CA: Thomson Wadsworth.
 Barrachina, J., Campins, J., Pascual, J.  C., & Soler, J.  (2005).  Double-Blind, Placebo-Controlled Study of Dialectical Behavior Therapy Plus Olanzapine for Borderline Personality Disorder.  The American Journal of Psychiatry, 162, 1221-1225.
 Frankenburg, F.  R., Hennen, J., Reich, D.  B., Silk, K.  R., & Zanarini, M.  C.  (2004).  Axis I Comorbidity in Patients With Borderline Personality Disorder: 6-Year Follow-up and Prediction of Time to Remission.  The American Journal of Psychiatry, 161, 2108-2115.
 Kaplan,H.  I., Sadock  ,B.  J., &  Sadock,V.  A.  Comprehensive Textbook of Psychiatry.  (7th ed.). (2000).  Philadelphia, PA: Lippincott Williams & Wilkins.
 Langley, J., Links, P.  S., & Vijay, N.  R.  (2006).  Adolescents Personality Disorders in Adolescent Medicine.  Adult Medical Clinics, 17, 115-131.  
 Oldham, J.  M.  (2006).  Borderline Personality Disorder and Suicidality.  The American Journal of Psychiatry, 163, 20-27.  
 Paris, J.  (2005).  Borderline Personality Disorder.  Canadian Medical Association Journal, 172, 1579-1584.
 Sansone, L.  A.., &  Sansone, R.  A., (1991).  Borderline Personality Disorder: Office Diagnosis and Management.  American Family Physician, 44, 194-198.
Townsend, M.  C.  (2003).  Psychiatric Mental Health Nursing: Concepts of Care.  Philadelphia:   F.  A.  Davis Company

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