The Personality Disorders Institute offers the following information
to the general public to enhance awareness of the particulary
challenging psychiatric conditions known as borderline disorders or
borderline personalities. Many patients struggle not only with
symptoms such as depression, anxieties, obsessions or phobias for
which help is typically sought, but also with control of emotion and
agression, understanding of self, and tolerance of the treatment
process.
The discussion leads you through diagnosis, focusing on history and
symptoms, and possible causes, treatments and outcomes. Contact and
emergency information follows.
I. DIAGNOSIS
The term "borderline" goes back a long way. For centuries, European
society excluded people regarded as "insane" from normal life,
confining them to asylums or driving them from one town to another.
By the 18th century, a few doctors were beginning to study the people
in asylums, and discovered that some of these patients had, by no
means, lost the powers of reason: they had a normal grasp of what was
real and what wasn't, but they suffered terribly from emotional
anguish through their impulsiveness, ragefulness, and a general
difficulty in self-government caused others to suffer. They seemed to
live in a borderland between outright insanity and normal behavior
and feeling.
These people, who were neither insane nor mentally healthy, continued
to puzzle psychiatrists for the next one hundred years. It was in
this "borderland" that society and psychiatry came to place its
criminals, alcoholics, suicidal people, emotionally unstable and
behaviorally unpredictable people; and to separate them off both from
the frankly insane at one border (those, for example, whose illness
we have come to call schizophrenia and manic-depressive or "bipolar"
disorder), and from "normal" people at the other border.
About a hundred years ago, a bright but very ill young woman found
that if her doctor listened to her for hours while she told him about
her inner experience and her memories, the symptoms that were making
her life unbearable would gradually subside. The patient recovered
and went on to become the first social worker in Germany.
Her doctor, Dr. Breuer, went on to become one of the teachers of
Sigmund Freud, inventor of the "talking cure" -- psychoanalysis. At
first the students of Freud thought that the talking cure would help
all mentally ill people except those who were seriously psychotic.
But over the years they found themselves dealing with some patients
who were in the same "borderland" described before: people who were
not psychotic, but who did not respond to the talking cure in the way
the therapists expected. Gradually, therapists began to define this
"borderline" group not so much by their symptoms as by the special
problems that were underneath the symptoms, and by the effects these
people had upon others.
The symptoms of borderline patients are similar to those for which
most people seek psychiatric help: depression, mood swings, the use
and abuse of drugs and alcohol as a means of trying to feel better;
obsessions, phobias, feelings of emptiness and loneliness, inability
to tolerate being alone, problems about eating.
But, in addition, the borderline people showed great difficulties in
controlling ragefulness; they were unusually impulsive, they fell in
and out of love suddenly; they tended to idealize other people and
then abruptly despise them. A consequence of all this was that they
typically looked for help from a therapist and then suddenly quit in
terrible disappointment and anger.
Underneath all these symptoms, therapists began to see in borderline
people an inability to tolerate the levels of anxiety, frustration,
rejection and loss that most people are able to put up with, an
inability to soothe and comfort themselves when they become upset,
and an inability to control the impulses toward the expression,
through action, of love and hate that most people are able to hold in
check. And, furthermore, what most defines the "borderline"
personality, is great difficulty in holding on to a stable,
consistent sense of one's self: "What am I?" these people ask. "My
life is in chaos; sometimes I feel like I can do anything--other
times I want to die because I feel so incompetent, helpless and
loathsome. I'm a lot of different people instead of being just one
person."
The one word that best characterizes borderline personality is
"instability." Their emotions are unstable, fluctuating wildly for no
discernible reason. Their thinking is unstable--rational and clear at
times, quite psychotic at other times. Their behavior is
unstable--often with periods of excellent conduct, high efficiency
and trustworthiness alternating with outbreaks of babyishness,
suddenly quitting a job, withdrawing into isolation, failing.
Their self control is unstable--ranging from the extreme self denial
of anorexia to being at the mercy of impulses. And their
relationships are unstable. They may sacrifice themselves for others,
only to reach their limit suddenly and fly into rageful reproaches,
or they may curry favor with obedient submission only to rebel, out
of the blue, in a tantrum.
Associated with this instability is terrible anxiety, guilt and
self-loathing for which relief is sought at any cost--medicine,
drugs, alcohol, overeating, suicide. Sadly, oddly, self mutilation is
discovered by many borderline people to provide faster relief than
anything else--cutting or burning themselves stops the anxiety
temporarily.
The effect upon others of all this trouble is profound: family
members never know what to expect from their volatile child,
siblings, or spouse, except they know they can expect trouble:
suicide threats and attempts, self-inflicted injuries, outbursts of
rage and recrimination, impulsive marriages, divorces, pregnancies
and abortions; repeated starting and stopping of jobs and school
careers, and a pervasive sense, on the part of the family, of being
unable to help.
And, of course, the effect of the illness upon the life of the
patient is equally profound: jobs are lost, successes are spoiled,
relationships shattered, families alienated. The end result is all
too often the failure of a promising life, or a tragic suicide.
II. CAUSES
What causes the illness that has come to be called Borderline
Personality Disorder? No one cause has been identified. Instead, most
cases seem to reflect a combination of contributing factors that
include an inherited vulnerability, a particular temperament, early
life experiences, and subtle neurological or hormonal disturbances.
All of these factors interact with each other and, in turn, produce
reactions in the parents and teachers of small children that often
intensify the problem.
First of all, as to inherited vulnerability, evidence for a genetic
factor in at least some cases comes from a recent study in which
borderline personality disorders were considerably more frequent
among the identical twins of borderline patients than they are in the
general population. Such studies suggest but by no means prove an
inherited tendency. Borderline patients have more relatives with mood
disorders, alcoholism and suicide than do people who do not have
borderline personality disorders.
As to temperament, as we all know, babies differ widely in their
physical and emotional stability. It is likely that those babies who,
from the start, are hard to console, are irregular in patterns of
feeding and sleeping, and who react with unusually intense rage to
frustration or pain are the ones most likely to develop into
borderline personalities. But by no means do all difficult infants
become ill with borderline disorders as adults. In addition, mothers
of some borderline patients describe them as having been unusually
easy, tranquil babies.
Regarding early life experience, many borderline patients have had
more than their share of hardship in infancy and early childhood.
They have been physically, sexually and emotionally abused. They have
had multiple caretakers. They have lost parents through death or
divorce. They have had frequent and painful illnesses. Yet, not all
children who have suffered in these ways become borderline
personalities. And some people who grow up in stable families and
seem to have had no unusual childhood hardships nevertheless develop
the pattern of borderline personality.
Neurological and hormonal patterns: Many borderline adults have had
developmental problems in childhood. Many others have had various
learning disabilities. Some have had seizures, or show abnormalities
in their brain waves. Still others experience an unusual degree of
trouble with their menstrual cycle once they enter puberty. But
again, not all borderline patients have these problems, and not all
people with these problems have borderline personalty disorders.
One can readily see, however, how all these elements would interact;
a fretful, inconsolable child who can't get on a regular feeding
schedule, can't sleep through the night, and has temper tantrums for
no apparent reason, can convert an ordinary good mother into a
nervous, short-tempered one. Parents' inability to comfort and soothe
a troubled infant all too often eventually triggers rage and
abusiveness in parents who could maintain better self control with a
child who responded to them in expectable ways.
Two experiences in growing up are very, very common among borderline
people. One is the experience of being seen as apparently competent.
Because these people often are in fact very competent, very smart,
sensitive, clever, insightful, it is extremely difficult for others
to take them seriously when they collapse in despair at a minor
frustration, burst into rage over nothing, make terrible errors of
judgment. When a psychotic person acts that way, people are inclined
to be sympathetic--"He can't help it"--but a borderline person is
told, "It's not that bad." "Shape up--grow up--don't be such a
wimp--you know better." Their behavior is often regarded as wilful,
manipulative, "just looking for attention."
The second experience is linked to that of being an apparently
competent person--and that is the experience of being invalidated:
"It can't be that bad." "Your headache--your PMS--your anxiety aren't
any worse than anybody else's--why make such a fuss?" Being
invalidated compounds the borderline person's self-hatred. The
majority of cases of borderline personality that come to the
attention of psychiatrists are women. We don't know why this is, but
researchers speculate that it reflects the combined effect of more
girls than boys being subjected to sexual abuse in childhood, and of
the tendency of males to express emotional instability via violence
toward others rather than via self-destructiveness. Borderline men,
therefore, are more likely to show up in jails than in psychiatric
hospitals or psychiatrists' offices.
III. TREATMENT
By the time a family member has been diagnosed as suffering from a
borderline personality disorder, so much stress has been generated in
the family that everyone is affected. For this reason, it is
advisable for the entire family to seek professional help initially.
Often various family members find that they need and want individual
therapy as their problems become clearer in the family work.
The individual outpatient psychotherapy for the borderline patient
usually consists of 2-3 therapy sessions a week over a period of
years. The therapist works with the patient to understand the
meanings and motives of his or her behavior, and to strengthen his or
her capacity to endure frustration, anger and loneliness without
acting impulsively upon those feelings.
Most borderline patients need a psychotherapy that focuses
consistently upon the feelings that underlie their problem of
"thinking in black and white," experiencing others or themselves as
wonderful at some times and as worthless at other times. Families may
need counseling throughout the first several years of psychotherapy
in order to provide the emotional support the patient needs and to
avoid harmful interactions with the patient. Appropriate support may
include learning to set limits with the patient rather than give in
to threats or unreasonable demands.
Medication may be needed as part of outpatient treatment. Patients
with marked mood swings sometimes benefit from two drugs ordinarily
used to treat epilepsy (Depakote or Tegretol). Patients with severe
depression or eating disorders may benefit from antidepressant
medication. Small doses of the neuroleptic drugs typically used for
schizophrenia sometimes help borderline patients in periods of severe
stress. Lithium is sometimes helpful, and may make it possible to use
lower doses of other drugs. Minor tranquilizers (like Valium), or
sedatives (like Dalmane) should be considered only with caution since
they are dangerously habit forming.
If outpatient therapy reaches a stalemate or is interrupted by
repetitive suicide attempts, or if the patient cannot stay
consistently with a therapy and continues to disrupt his or her own
life and that of others, the family and patient may want to seek
consultation in a center specializing in the treatment of borderline
personality disorder. A thorough assessment may lead to the
recommendation of a more specific individual therapy, adjunctive
group or family therapy, referral to substance abuse treatment, or
more intensive treatment in the form of hospitalization or a day
hospital program.
Day hospital treatment is helpful both in enabling patients to
understand their problems and how these affect others, and also in
bringing patients into close daily contact with others who are
working on those problems. Borderline patients tend to support each
other--sometimes in a negative way, to be sure, but more often in a
very positive way. Articulate, candid and forthright, they are often
extremely effective in cutting through the denials and excuses and
the blaming of others that so hamper a person's ability to see his or
her own problems. The recognition of the illness and the
determination to overcome it have everything to do with successful
treatment.
IV. COURSE AND OUTCOME
Without adequate treatment, the illness if lifelong, and all too
often ends in suicide. With good treatment, the outlook is very
favorable indeed in many cases. Among the 500 borderline patients
studied by Dr. Michael Stone at the Columbia Psychiatric Institute
over more than 20 years, 4 out of 10 are clinically recovered 10-20
years after their point of entry into the study during
hospitalization. Seventy-five percent are self-supporting and doing
reasonably well. The suicide rate was 7% as of 16 years
post-admission. The patients who recovered tended to be those who
persisted in psychotherapy over many years.