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-injury 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.

Since the time Dr. Stone began his study, the members of the Personality Disorders Institute have continuously been studying borderline personality disorder and its treatment. We work under the leadership of Dr. Otto F. Kernberg, the world's leading expert on Borderline Personality Disorder, whose books and articles have, since 1971, provided a foundation for how to understand and treat borderline personality.

Our understanding of the disorder and how to treat it effectively continues to increase. We offer a full range of clinical services at our facility in White Plains, New York. We currently offer outpatient therapy in Manhattan, with plans to expand services there in the future. Inquiries are welcomed at the following phone numbers:

For outpatient therapy--The Ambulatory Adult Education Services at 914-997-5940

For hospital treatment--The Evaluation Center at 914-997-5700

For private referrals--Dr. John Clarkin at 914-997-5911

At the current time, we are focusing on providing services to people in the metropolitan New York area.  We have colleagues in some other geographical areas, but unfortunately are not able to provide referrals for all areas.