Patients With Borderline Personality Disorder example essay topic

Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity. Originally thought to be at the "borderline" of psychosis, people with BPD suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women. There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.

Yet, with help, many improve over time and are eventually able to lead productive lives. While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression and anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are.

Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone. People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthlessness.

Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments. People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders. Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients.

Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies. 6 Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and / or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.

Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children. Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver. Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.

NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsively, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. 10 The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit.

Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion. Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure. Studies that translate basic findings about the neural basis of temperament, mood regulation and cognition into clinically relevant insights-which bear directly on BPD-represent a growing area of NIMH-supported research.

Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990's, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.

Diagnostic Criteria A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation identity disturbance: markedly and persistently unstable self-image or sense of self impulsivity in at least two areas that are potentially self-damaging (e. g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior affective instability due to a marked reactivity of mood (e. g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) chronic feelings of emptiness inappropriate, intense anger or difficulty controlling anger (e. g., frequent displays of temper, constant anger, recurrent physical fights) transient, stress-related paranoid ideation or severe dissociative symptoms Medical Treatment Basic Principles Persons with borderline personality disorder are very vulnerable, and usually over-react to stress (especially medical illness). Borderline patients usually form unstable and intense "love-hate" relationships, thus they view their medical caretakers as either "all-good", or if any problems occur, "all-bad". Initially they may view their physician as the "rescuer", then suddenly switch and view their physician as the "villain". Therefore, the physician must avoid falling into the trap of being idealized by the patient, and then being pitted against other caregivers who the patient hates.

The borderline patient's anger usually alienates potential caregivers, yet these patients make frantic efforts to avoid real or imagined abandonment. Thus it is vitally important that the physician tolerate the patient's episodic angry outbursts to demonstrate to the patient that the physician will not abandon the patient (as the patient angrily expects and fears). Recent research has shown that medications can significantly relieve the suffering of borderline patients when used in combination with psychotherapy. Hospitalization Due to their suicide attempts, or brief psychotic episodes, borderline patients frequently are hospitalized. Both admission and discharge from the hospital emergency room are usually difficult, due to the borderline patient's power struggles with caregivers and family. Usually all that can be accomplished in the emergency ward is crisis intervention, and immediate discharge home with return to the care of the outpatient therapist.

If the patient has no therapist, the emergency ward staff should attempt to find an outpatient therapist. Otherwise, without an outpatient therapist, borderline patients usually keep coming back to the emergency ward in crisis after crisis. The emergency ward staff must be careful not to let borderline patients pit the hospital staff against the outpatient therapist. Sometimes the crisis is so severe that short-term hospitalization is needed.

Often it is only after a short-term hospitalization that the diagnosis of Borderline Personality Disorder can be accurately made. During hospitalization, closeness with the patient should be developed gradually with gentle, but firm limits. Unfortunately, borderline patients can often regress and start to mimic the behaviors of the more psychotic or dysfunctional patients on the ward. Unless the treatment environment is highly structured and the staff are well-experienced, increased acting-out or regression by the borderline patient may be encountered.

Thus long-term hospitalization is usually counter-productive for borderline patients with high regressive potential. Antipsychotic Drugs During brief reactive psychoses, low doses of antipsychotic drugs (e. g., haloperidol or respiridone) may be useful, but they are usually not essential adjuncts to the treatment regimen, since such episodes are most often self-limiting and of short duration. Depression in some cases is amenable to antipsychotic drugs. These drugs can also be used successfully to control the borderline patient's anger. Dosages should generally be low and the medication should never be given without adequate psychosocial intervention. Antidepressant Drugs Monoamine oxidase inhibitors have been used for patients with borderline personality disorder who are unduly sensitive to rejection.

These patients experience intense anxiety and depression when they feel rejected. Other antidepressants have also been found to be effective in reducing this intense anxiety and depression. Antianxiety Drugs Brief use of antianxiety medication may be required to relieve the episodic, intense anxiety of borderline patients. Long-term use of antianxiety medication should be considered only with caution. to top Psychosocial Treatment Basic Principles Borderline patients are fragile and prone to rapid deterioration.

Many borderline patients will only see a therapist during a crisis. The therapist's crisis intervention should focus on solving the patient's "here-and-now" problems, despite the patient's frequent tendency to avoid reality-oriented problem-solving. Brief crisis intervention can dramatically decrease the borderline patient's suicide attempts and need for emergency hospitalization. After the crisis intervention phase of therapy is over, the longer maintenance phase focuses on both conflict resolution and social learning designed to minimize regression. The treatment of borderline personalities should not be undertaken without support for the therapist, such as readily available consultation, and a cooperative hospital that serves as back-up during periods of severe regression and heightened suicidal risk.

Individual Psychotherapy Regardless of the type of long-term psychotherapy used, two important issues in therapy must be addressed: the setting of limits, and reality-oriented problem-solving. Borderline patients need many hours of psychotherapy just to learn how to set limits for their own behaviors and how to respect other people's limits. Many additional hours of psychotherapy usually are needed to overcome their overuse of fantasy and problem-avoidance, and to teach them reality-oriented problem-solving. Unfortunately, few borderline patients are sufficiently motivated to persist with long-term psychotherapy. Some patient's acting out can be so dangerous as to make long-term psychotherapy impossible.

Long-term psychotherapy with a borderline patient is very demanding. The therapist must be able to tolerate repeated episodes of the patient's rage, distrust, and fear. The goals of therapy should be in terms of supporting life gains toward independent functioning, and not complete restructuring of the personality. Group Therapy Group treatment should be supportive rather than exploratory, especially in the outpatient setting.

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 Cau wels 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, Jonathan 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: Affect chronic / major depression helplessness hopelessness worthlessness guilt anger (including frequent expressions of anger) anxiety loneliness boredom emptiness Cognition odd thinking unusual perceptions non delusional paranoia quasi psychosis Impulse action patterns substance abuse / dependence sexual deviance manipulative suicide gestures other impulsive behaviors Interpersonal relationships intolerance of aloneness abandonment, engulfment, annihilation fears counter dependency 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.

Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. Zanarini MC, Yong L, Franken burg FR, Henne n J, Reich DB, Marino MF, Vujanovic AA. The Laboratory for the Study for Adult Development, McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02478, USA. This study has two purposes.

The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semi structured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment.

It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder. Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan Publisher: Guilford Press; (May 14, 1993) 558 pgs.