THE BORDERLINE PERSONALITY DISORDER
NEW MANAGEMENT CONCEPTS

INTRODUCTION

The Borderline Personality Disorder (BPD), a psychoneurological disorder affecting tens of millions [1,2] is now treatable with a combination of medication and other therapies. Fortunately fluoxetine (Prozac) [3] and low dose intermittent neuroleptics [4] can stop most of the mood swings, and many of the irrational behaviors. Untreated, these patients suffer from very painful, difficult lives - and a caring health care professional can make a profound difference.

GENERAL DESCRIPTION

According to Dr. Rex Cowdry of the NIMH the "BPD is characterized by tumultuous interpersonal relationships, labile mood states, and behavioral dyscontrol set against the background of a relatively stale character structure. While the syndrome can be identified with reasonable reliability, the fundamental nature of the disorder remains unclear..." [ 5] See Table 1 for the DSM-III-R criteria. It is a worldwide phenomenon, being described in the U. S., England, Scotland, Switzerland, Germany, France, Norway, and Japan. [6] It likely affects approximately 2-3% of men and 5-10% of women. [1]

Prior to effective medical therapy, managing borderlines was a difficult struggle. Articles in Family Physician [7] and Nursing [8] journals describe them as demanding, manipulative, disruptive, frustrating, non-compliant, and hostile - especially when not medicated properly.

WHAT BORDERLINES EXPERIENCE

Untreated, a borderline lives an emotional vertigo - experiencing totally unstable moods. These mood swings and most any stress cause a horribly progressive dysphoria. They intensely feel almost every painful emotion at once.

Borderlines desperately search for relief, usually by endorphin releasing behaviors that are ultimately self-destructive - such as binge eating, binge spending, aberrant sexual behavior, substance abuse, and reckless driving. When a severe borderline is extremely dysphoric, cutting the skin causes no physical pain and actually relieves the dysphoria.

Because untreated borderlines live with constant mood swings and frequent dysphoria, normal psychological functioning is crippled. Understanding this enables the Family Physician to help. Borderlines need to understand their illness, and to be treated properly.

MAJOR SYMPTOMS

Mood Swings: Mood swings are a fundamental devastating symptom of borderline. Moods can shift inappropriately from hour to hour, even minute to minute. Without appropriate environmental of though-provoked justification. [9]

Dysphoria: A combination of depression, rage, anxiety, and despair - often complicated by shame, humiliation, embarrassment, excitement, terror, jealousy, and self-hate. It can be triggered by mood swings, stress, and emotional pain. Once dysphoria begins, it tens to steadily intensify - possibly due to limbic system malfunction. [5] The sensation is so painful that borderlines will desperately search for a way out - often relying on drugs, alcohol, self-destructive and impulsive behaviors, self-mutilation, and suicide. [9.10]

Psychosis: Psychotic thinking often develops when the dysphoria becomes severe. Because of the psychotic episodes, borderlines are said to live at the "border" between reality and psychosis. The main psychotic symptoms are moods, physical sensations and perceptual distortions.

The dominant psychotic moods center around worthlessness, badness, rage, and self-destruction. The physical sensations are remarkably similar to temporal lobe epilepsy and include unreality, derealization (familiar things become unreal). Deja-vu, out-of-body experiences, depersonalization (as though no longer yourself), unawareness spells, and feeling like body parts are numb and no longer part of oneself. [9]

Psychotic perceptual distortions primarily include transference (incorrectly perceiving a present day person to be like someone hurtful from the past), inappropriate interpretation of motives, and hallucinations. Psychosis can also be brought on by drugs, especially alcohol and marijuana. [1]

Splitting: Small children see everything in life as being all good or all bad. This immature psychological defense persists in borderlines, resulting in "black and white thinking." When life events are perceived as bad, dysphoria usually results. When things are good, the borderline frequently feels vulnerable, and fears the black returning - often leading again to dysphoria.

Other symptoms: A borderline’s life is defined by inconsistency - mood, identity, trust, behavior, attitudes, values and thoughts. While intelligence is not impaired, [11] organization and structure are [12] - borderlines have trouble following through and completing tasks. Access to memory is frequently impaired. Chronic anger, fear of abandonment (often resulting in manipulative behavior), lack of trust, impulsivity, feelings of emptiness and/or boredom, jumping to incorrect conclusions, and severe PMS are commonly experienced.

Comorbidity: Borderlines frequently suffer from other psychiatric illnesses. The most common include depression, [1] anxiety, [13] substance abuse, alcohol abuse, [14] other personality disorders, and eating disorder (approximately 40% of eating disorder inpatients suffer from the borderline). [15] There is no association with schizophrenia. [16]

ETIOLOGY

Psychological theories alone cannot explain the BPD. Borderlines have significant biological abnormalities - see Table 2. CNS serotonin malfunction is likely involved. Temporal lobe dysfunction is often associated with stress. The BPD is probably a medical predisposition combined with environment insult.

There are many psychological theories and concepts, with considerable disagreement among experts in the field. Both overprotective and underprotective parents have been "blamed" as the cause. [16] Most theories center around traumatic childhood experiences, arrested psychological development (especially at the separation/individuation phase), and reliance on maladaptive coping and survival mechanisms. [23,28]

Adoption, early parental loss, and incest are often associated with the BPD. [14] The most severe borderline patients suffered from both sexual and physical abuse, usually while very young [6] - chronic dysphoria and derealization are the best predictors. [29] In one study, 81% reported major childhood trauma, 71% physical abuse, 68% sexual abuse, and 62% witnessed serious domestic violence. [30]

Genetics: The BPD tends to run in families, six times more likely in first degree relatives. There is an increased family history of alcoholism, substance abuse, other personality disorders, and depression, but not schizophrenia. [16]

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