Overview of Borderline Personality Disorder

The Personality Disorders Institute offers the following information to the general public to enhance awareness of the particularly challenging psychiatric conditions known as borderline disorders or borderline personalities. Many patients with these disorders 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-governance 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—to separate them off both from those with more clearly defined psychiatric illnesses 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, alcohol, or food as a means of trying to feel better; obsessions, phobias, feelings of emptiness and loneliness, inability to tolerate being alone.

In addition, these patients displayed 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. What seems to be of central importance in the symptoms and difficulties mentioned above is that the hallmark of 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." Emotions are unstable, fluctuating wildly, often for no discernible reason. Thought processes are unstable—rational and clear at times, quite extreme and distorted at other times. Behavior is unstable—often with periods of excellent conduct, high efficiency and trustworthiness alternating with outbreaks of regression to childlike states of helplessness and anger, suddenly quitting a job, withdrawing into isolation, failing.

Self control is unstable leading to impulsive behaviors and chaotic relationships. A person with borderline personality disorder may sacrifice themselves for others, only to reach their limit and suddenly fly into rageful reproaches, or they may curry favor through 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. Research has suggested that childhood physical and sexual abuse, early parental loss due to death or divorce, multiple caretakers, such as foster care, and parental neglect are among the risk factors for development of a personality disorder. 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 personality disorders.

One can readily see 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 common in borderline disorders. 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 willful, 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 isn'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 outward aggression 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 they affect others, and also in bringing patients into close daily contact with others who are working on similar 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, peers 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. 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 is lifelong, and all too often ends in a severely unfulfilled, constricted existence, or worst case, 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 across 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.