Borderline Personality Disorder: Psychiatry’s Mysterious and Misunderstood Diagnosis

Trish Carlson, MD

 Borderline Personality Disorder is a condition that affects millions in the United States and worldwide yet is still a relatively misunderstood diagnosis.  It resides under the larger umbrella of diagnoses called “Personality Disorders”, a group of disorders that, despite clinicians’ ongoing efforts to clarify their meaning, remain a rather confusing, vague, and elusive bunch.

 The Diagnostic and Statistical Manual IV, Revised Edition (DSM-IV), is the mental health clinician’s ‘bible’ of diagnoses and defines a Personality Disorder as “enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.”   The term ‘personality disorder’ is the somewhat clumsy nomenclature used to designate the ineffective use of one’s inherent personality to effectively navigate interpersonal relationships and functional demands of life.

 The DSM-IV currently defines ten personality disorders and Borderline Personality Disorder is perhaps the most common, yet most debilitating disorder of them all.  Various recent epidemiological studies have estimated that 2-6% of the population has the disorder, essentially millions of people out there.  The term ‘Borderline’ stems from early psychoanalysts’ attempts to describe a patient whose symptoms lay between the neurotic and psychotic spectrum of disorders.  Today, the disorder is much better understood and current clinicians are aware that the term is a misnomer that is prone to cause issues due to the history and stigma that often accompanies the name.  The latest edition of the manual, the DSM-V, is currently in the works, and will attempt to simplify and better define all categories of personality disorders.  In the meantime, there is often hesitation to diagnose these disorders and clinicians may avoid using the term ‘personality disorder’ when talking to their patients.  The ongoing issue with this is that patients may not fully understand what they are up against.    But before continuing any further, let’s take a look at some of the hallmarks associated with Borderline Personality Disorder:

Patients with BPD typically experience the following symptoms:

-          Instability of mood, often with anger and irritability

• Emotions can quickly change from elated to depressed, or content to angry in a matter of minutes or hours.  The patient is often very sensitive and has little ability to tolerate unpleasant emotions.

-          Frequently chaotic relationships with intense fear of abandonment

• Relationships often follow a ‘love-hate’ type cycle; one minute all is well and the next, full out war has broken out.  Patients appear to overreact over the slightest of disagreements.
• Patients can be so fearful of abandonment by others that their desperate actions end up pushing people away.  This results in the very abandonment that they desperately try to avoid.

-          Confused sense of self or feelings of emptiness

• Patients often feel lost, or uncertain about their own identity.  They look to external cues to validate their thoughts, behavior or emotions.  They may feel alienated and change their behavior or beliefs in order to be found acceptable by others.  They have no grounding in their own sense of self.

-          Impulsive behavior

• Patients often have poor impulse control.  They may act in ways that are self-destructive or dangerous such as reckless driving, excessive drinking, over-eating, or deliberate self-injury like cutting themselves. They may even attempt suicide.

-          Cognitive Dysregulation

• Patients may transiently dissociate from reality, or experience brief periods of paranoia.

In a nutshell, BPD is a disorder characterized by significant mood instability and emotional dysregulation that worsens in times of stress.

What makes BPD so tough? 

The suffering associated for all parties involved with BPD is high.  The person with the disorder is in frequent turmoil and distress.  They experience emotions all over the chart, feel out of control and misunderstood.   To complicate matters, they frequently carry additional diagnoses such as depression, anxiety, eating disorders or substance abuse, which further impair functioning.  According to data from the NIMH-funded National Comorbidity Survey Replication, about 85 percent of people with borderline personality disorder also meet the diagnostic criteria for another mental disorder,¹

Patients with BPD often cycle through many doctors desperately seeking relief.  Unfortunately, medications don’t ‘cure’ the disorder but may put an inadequate Band-Aid on the symptoms.  Patients may be prescribed numerous medications without sustained or significant improvement, leading to more frustration.  They feel like no one can understand or help them.  Because they can be impulsive with low frustration tolerance, they often give up and drop out of treatment, until the next crisis brings them back desperately seeking help.

The family members of BPD patients suffer as well.  They are the reluctant passengers on the patient’s emotional roller coaster, desperately wanting the unpredictable ride to end. It’s uncertain what mood or emotional state they will encounter on any given interaction with the patient.  One day things are calm and perfect, the next day, complete pandemonium.  Family members have trouble understanding the patient’s behavior and have tried all the common sense strategies they know to help the patient with limited, if any, success.  Their attempts to help may be met with distain and anger from the patient and over time this becomes exhausting.  Families become frustrated, perplexed and fed up with the patient and may want to throw in the towel as well.

Finally, the psychiatrist struggles to offer relief to both the patient and the family, often feeling inadequate and ineffective. Sessions with the patient can be unpredictable.  Some interactions go extremely well, others end with the patient exiting in a ball of fury.  Doctors may receive frequent calls by the patient threatening suicide or self-harm. They may attempt to control the patient’s symptoms with medications, which can help to a degree, but still the underlying etiology for the symptoms is not fully addressed, so the suffering for all parties involved continues.

Barriers to Optimal Treatment

One issue that creates an obvious barrier to effective treatment is the fact that many patients with the disorder are unaware that they have it!

So why don’t all of the capable clinicians in the world let the cat out of the bag and just tell their patients this could be part of their diagnoses?  One reason relates to the desirable, yet unrealistic aim for both a correct and quick diagnosis in our current managed healthcare system.  Psychiatrists are typically allotted about one hour to assess a patient and make a diagnosis. They understandably hesitate to make an observation about a patient’s overall, prevailing personality after just one appointment.  There may be strong suspicion of personality disorder on a first meeting, but it would be premature, not to mention unfair to the patient, to diagnose a personality disorder at this point.  Also, some of the symptoms of BPD may overlap with other mental disorders such as bipolar disorder or anxiety disorders, making definitive diagnosis more difficult.

Doctors want to be sure that the presenting symptoms are not due to a transient acute stressor or other biological mental illness before assigning a diagnosis of BPD.    Short appointment times dictated by managed care make it hard for clinicians to really get to know their patients and it is necessary for a clinician to work with a patient over time to make an appropriate diagnosis of BPD.

Furthermore, patients with the disorder often feel misunderstood and frustrated and can be very sensitive.  If a clinician starts talking about a personality disorder too early in the treatment relationship, before a therapeutic alliance can be established, the patients may not return for treatment with that practitioner.  Then they start treatment with a different clinician who has to start from scratch with them all over again.

Finally, the good news…

Yes, there is some good news:  A proper diagnosis of BPD can provide relief to patients and families of those with the disorder.  The right diagnosis can shed some light on the behaviors that have caused impairment for such a long time.  As for ‘bad’ news: unfortunately, there is no magic pill or treatment that can quickly cure BPD. Improvement requires time, hard work, dedication and patience from both the clinician and the patient, and this reality can be daunting for some patients.

The mainstay of treatment for BPD is long term psychotherapy. One goal of the therapy is to reduce the frequency of borderline behaviors to help the patient be more functional in society.  One of the most successful types of therapy used to treat BPD is Dialectical Behavior Therapy (DBT), developed by Dr. Marsha Linehan, Professor of Psychology, University of Washington, in the late 1970’s.  It is based on a “bio-social” theory that states that a individual’s problems likely develop from the interaction of biological factors (one’s genetic and physiological makeup) in addition to environmental factors (circumstances of upbringing and learned history), which together create difficulty managing emotions in an effective way.

Dialectical Behavioral Therapy (DBT) combines ideas from cognitive and behavioral therapy, as well as the Eastern meditative tradition of mindfulness.  The core of DBT focuses on reducing incidence of self harm or other behaviors that lead to a decreased quality of life, and teaches patients skills to help cope with stress, regulate emotions and improve relationships with others.  The therapy works to synthesize the juxtaposed ideas of accepting a patient as they are, while at the same time encouraging change to improve functioning.

Medications can also be used in conjunction with therapy to help with the mood swings and impulsivity that often accompany the diagnosis.  Patients with BPD are often prescribed medications of various classes which may include mood stabilizers, antidepressants and atypical antipsychotics, to name a few.  As stated earlier, medications can help control some of the symptoms of BPD, but usually are not the sole answer to the problem.

It is helpful for families of those with BPD to get support as well.  A first step involves getting more education about BPD.  There are numerous books available that help better understand the disorder.  There are also classes and support groups available for family members of those with BPD.  Also, family therapy involving patient and family members can also be extremely beneficial to the overall treatment course of the patient.

A recent study followed patients with BPD over 10 years and found that about 85% of the cases showed significant improvement, although remission was slower than that for patients with major depressive disorder and other personality disorders studied.  (Gunderson et al, 2011)  Overall, the study found that the long term course of BPD is characterized by high rates of remission, low rates of relapse, but noted that there was still persistent impairment in social functioning for patients with BPD.   These results are important in that they can help set reasonable expectations for patients, families, and clinicians.

Overall, if you or someone you care for suffers from symptoms consistent with those of BPD, it is critical to seek help and get an accurate diagnosis.  If you are the patient with these symptoms, remember this: a diagnosis of a personality disorder in no way diminishes the fact that you are suffering and in distress!  It also does not rule out the possibility of a coexisting mental health disorder that may need treatment.  Give your mental health care provider a chance to get to know you and make the correct diagnosis so you can get the help you need.

Remember that remission of symptoms is possible.  There is hope for improvement.  Patients who stay in treatment can improve slowly over time. 

References:

1. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Sep 15;62(6):553-64.