Borderline disorder is a persistent pattern of emotional reactions, thinking and behaviour in which instability in interpersonal relationships, self-image, marked instability of emotions, impulsivity in reactions and behaviour predominate.
These begin to manifest themselves from adolescence and youth.
Borderline disorder is more common than people think. It has a prevalence of almost 6% in the general population and 10-20% in the psychiatric patient group.
Initially it was considered a more common disorder in women (90%), but recent studies have shown a frequency of 3:1 ratio of women to men, with under-diagnosis in men.
Borderline Disorder Symptoms
In order to make the diagnosis, according to the current criteria, the person must present 5 of the following 9 symptoms of borderline personality disorder:
(1) Desperate efforts to avoid real or imagined abandonment.
For example: the person tolerates break-ups extremely hard, tends to call/recall his/her partner very often, bears with anger and pain postponements, delays, refusals, will very frequently have jealousy attacks, with multiple accusations for the slightest real or imaginary violation of expectations, will accept the end of a relationship very hard, sometimes insisting for months/years with phone calls and messages. He/she may also have a hard time with the therapist’s vacations/absences/failures, with many moments of angry accusations about “how little he/she matters” to the therapist
(2) An accumulation of intense and unstable interpersonal relationships characterized by alternating extremes of idealization and devaluation.
The person frequently alternates in relationships of friendship, love, therapy, between moments of maximum emotional outpouring, in which the other is “wonderful/perfect/best”, and then, if he/she feels/perceives a rejection/breach of expectations, he/she thinks and reacts angrily, arguing that the other is “the worst/evil/terrible”. He may impulsively decide to “break off” the relationship, only to reverse the decision a little later, arguing the opposite.
In general, life and people are seen in “black and white”.
(3) Identity disturbance: marked and persistently unstable self-image or self-awareness.
The person may have frequent moments when their view of themselves is extremely negative, sometimes going as far as self-hatred and feelings of complete worthlessness, of worthlessness of their own existence. This alternates with moments of pride, of strong conviction of the rightness of one’s own opinions/feelings, possibly with devaluing/ironising others.
Opinions about what matters/wants to achieve in life are changeable. The person is, however, at all times convinced of the permanence of the current decision.
(4) Impulsiveness in at least two areas that are potentially harmful
(e.g., spending, sex, substance abuse, reckless driving, binge eating)
Unprotected sex, impulsive and sometimes compulsive, also occurs frequently in both sexes and can lead to serious diseases (HIV, hepatitis, etc.).
The person resorts to such behaviors as a mechanism to soothe extremely intense and painful emotions, to alleviate the pain felt related to abandonment, against boredom and inner emptiness, as an expression of hatred towards self/others or, on the contrary, as an expression of self-determination.
(5) Repeated suicidal behavior, gestures or threats, or self-injurious behavior.
The person often resorts to suicide threats and attempts as a solution to psychological problems, psychological pain, negative self-image. Often, the person may associate major depressive episodes. Suicide attempts are serious and complete suicide is possible.
Interpersonal relationships can be severely affected by these permanent dangers and vital emergencies, making it difficult for life partner, parents, therapists to continue relationships in such a dynamic.
Self-harm can be impulsive, done “on the nerves”, to soothe a psychological pain, to “awaken” a reaction when the psychological vacuum is too terrifying, as a method of self-control in the face of psychological and relational instability.
(6) Affective instability due to marked mood reactivity
(e.g. intense episodic dysphoria, irritability or anxiety usually lasting a few hours and rarely more than a few days).
Mood reactivity is one of the most painful aspects of BPD, because even emotional reactions to ordinary stimuli are extremely intense, “hot”, with the intensity of emotion reaching its maximum “temperature” very quickly. Their duration varies widely, from hours and days to weeks, and can sometimes warrant an additional diagnosis of major depression or anxiety disorder. Association with bipolar disorder or cyclothymia is common.
(7) Chronic feeling of emptiness.
People suffering from borderline personality disorder frequently describe this feeling of “inner emptiness” or “emptiness” as a complete lack of internal emotions, sometimes so strange and unbearable that they may resort to self-injury as a way of feeling something. Others describe the condition as a feeling of deep boredom or a lack of meaning in life stemming from a “I’m not OK, others are not OK, life has no meaning” stance on life.
(8) Intense, inappropriate anger or difficulty controlling anger
Abandonment, rejection or disappointment of expectations often cause extremely intense anger, for which justifications appear in waves, until the anger reaches a maximum intensity. Sometimes it leads to verbal or physical aggression, breaking of objects, other destructive acts done impulsively, but it can also be expressed through self-harm: either self-injury or engaging in acts that are aggressive towards oneself (drug use, dangerous sexual acts, compulsive eating).
(9)Paranoid ideation or severe, transient, stress-related dissociative symptoms.
As a justification for anger or devaluations of others, moments of paranoid ideation, sometimes of psychotic intensity, may occur for a short period of time and quickly subside. Other times dissociated phenomena occur, with feelings of derealization or dissociation: “it felt like I wasn’t me anymore, the world was cloudy, I felt like I was watching myself from the outside, etc.)
Tulburarea borderline cauze
Borderline personality disorder has stirred up a lot of controversy not only about its name and symptoms, but especially about its causes.
It is a biological disorder related to an instability of the brain?
Or is it generated by psychological factors, frequently associated with childhood trauma?
Borderline personality disorder has primarily psychological causes, linked to major childhood traumas. Verbal abuse, physical abuse, neglect, abandonment, sexual abuse. People with borderline personality disorder often (more than 90% of cases) have an extremely traumatic life history. With exposure to abuse, often in multiple ways and difficult to accept (e.g. children whose parents die prematurely or are killed, are abandoned, who are orphaned, go through multiple families. Who are beaten and humiliated horribly, with violent, aggressive or psychotic parents. They are tied up, locked up, neglected or sexually abused, sometimes even by siblings or parents).
One of the leading theories about the origins of borderline personality disorder is that it is a post-traumatic stress disorder that has become a personality mode. Trauma is particularly caused by or linked to trusted people, often with ambivalent behaviors that alternate between being violent and close. Example: parents, siblings, relatives, psychologically affecting the person’s ability to discern between “good and bad”, between “close, trusted, and enemy”.
Trauma is not mandatory.
Borderline disorder may also be caused by exposure to ambivalent parenting. With a mother who comes and goes, is close and then suddenly becomes cold or angry. It is said that mothers with borderline disorder raise children with borderline disorder.
Psychoanalytic theories believe that all people naturally go through a borderline period around the age of 18 months, in which the child alternates between being close to the mother and moving away from her to explore the world. Mother is perceived as either good or bad and not as a complete person with good and bad.
Biology also plays a causative role, as emotional instability and impulsiveness are not only learned but also inherited.
Conditions associated with Borderline Disorder
Borderline personality disorder is diagnosed under Axis II of personality disorders.
On Axis I it can be associated with any mental disorder, but more commonly with the following:
major depressive disorder
bipolar spectrum disorder
post-traumatic stress disorder
ADHD (attention deficit hyperactivity disorder)
impulse control disorder
eating disorders (bulimia, compulsive eating)
Treatment methods for borderline personality disorder
Treatment for borderline personality disorder is almost exclusively psychotherapeutic.
Drug treatment is recommended only when combined with other disorders.
Psychotherapy is generally a long-term therapy of 5 to 7 years. Psychotherapy is marked by many interruptions and changes of psychotherapists. Therefore, before deciding to stop treatment or change therapist, an analysis of the therapeutic relationship is necessary.
There are therapies specifically designed for borderline personality disorder whose effectiveness is supported by long-term studies:
1. Dialectical Behavioral Psychotherapy (DBT).
Developed by Marsha Linehan in the late 1970s, DBT became the gold standard for the treatment of borderline personality disorder. Recommended by all international guidelines and the World Health Organization.
It has proven effective in reducing suicidal behavior, self-harm, psychiatric hospitalization, and depression. It reduced treatment dropouts, reduced substance use symptoms, impulsiveness and anger. The quality of life and overall level of functioning has increased.
The DBT shall consist of:
intervention group for psychotherapists
Psycho-education groups are group therapies designed to train behavioral skills. The group is run as a class in which the group leader teaches skills and assigns homework for clients to practice in their daily lives.
The groups meet weekly for approximately 2.5 hours and it takes 24 weeks to achieve full competencies through the curriculum. It being often repeated to create a year-long program.
DBT includes four sets of behavioral skills:
Mindfulness: the practice of being fully aware and present in the moment.
Stress tolerance: how to tolerate pain and stress in difficult situations without changing them.
Interpersonal effectiveness: how to ask for what you want and say “no” while maintaining self-respect and relationships with others.
Emotion regulation: how to change the emotions you want to change.
2. Schema Therapy
It was developed by Dr. Jeffrey E. Young for use in the treatment of DSM Axis I personality disorders and chronic disorders when patients do not respond or relapse after undergoing other therapies. Schema Therapy is an integrative psychotherapy, combining theory and previously existing therapy techniques. Including cognitive behavioral therapy, psychoanalytic object relations theory, attachment theory and Gestalt therapy.
3. Mindfulness Based Treatment (MBT)
MBT is a form of psychodynamic psychotherapy, developed and manualized by Peter Fonagy and Anthony Bateman. MBT was designed for people suffering from borderline personality disorder, who suffer from disorganised attachment. And who, because of this, have failed to develop a capacity for mindfulness in the context of a secure attachment relationship.
The goal of treatment is for patients with borderline personality disorder to increase their ability to think. This should improve emotional regulation and stabilize interpersonal relationships.
4. Transfer Focused Psychotherapy (TFP)
It is a modified psychodynamic treatment, very structured, twice a week. It is based on the borderline personality disorder model of Otto Kernberg.
It sees the individual with borderline personality organization as holding representations of self and significant others. They are unreconciled and internalized contradictorily, representations with a great emotional charge and significance. Defending against these contradictory internalized object relations leads to disturbed relationships with others and with oneself.
Distorted perceptions of self or others and associated emotions are at the heart of treatment, as they arise in the relationship with the therapist (transference). The treatment focuses on integrating these separate parts of the self and representations of others. This is because consistent interpretation of these distorted perceptions is considered the main mechanism for change.
TFP is one of a number of treatments that can be useful in the treatment of borderline personality disorder. However, TFP alone has been shown to change the way patients think about themselves in relationships.
Treatment for borderline personality disorder at Hope Clinic is based on the theory of dialectical-behavioral therapy!
The treatment combines elements of our training in transactional analysis, psychoanalysis and cognitive behavioral therapy, in accordance with at least some of all the above theories.
DBT is itself a combination of elements from all types of psychotherapy, with an important focus on the therapeutic relationship. The significant factor being the phasing of therapy, considering that psychoanalytic interpretations are intended for the later stages of therapy.
Borderline disorder treatment
Treatment for borderline personality disorder is almost exclusively psychotherapeutic. Drug treatment is for co-morbidities.
Borderline personality disorder is a condition marked by intense emotional, relational and self-image instability.
Hope Clinic has all the options available to treat borderline personality disorder.
We only have therapists adequately trained to work in individual psychotherapy. They focus on raising awareness of the difficulties and peculiarities of working with people suffering from borderline personality disorder.
We offer specialized training and continue to train in dialectical-behavioral therapy.
Unlike other clinics, our psychiatrists have advanced knowledge in recognizing the disorder. We recommend psychotherapy as first-line treatment. We only treat with medication the associated pathology (anxiety disorders, depression, bipolar disorder, etc).
“FIND YOUR BALANCE” PROGRAMME
The particularity of psychotherapeutic treatment in borderline personality disorder is that in parallel with individual psychotherapy it is necessary to develop a set of psychological skills. They allow the client to improve their symptoms faster and increase their quality of life.
4 sets of techniques and skills are taught
Techniques for being fully aware of all aspects of life. It teaches content skills – “what mindfulness is” (observing, describing, participating) and process skills – “how to do mindfulness” (non-judgmental, one thing at a time, effectiveness.
How to tolerate pain and stress in difficult situations, crisis management strategies
3. Interpersonal effectiveness
3. Interpersonal effectiveness
4. Emotion regulation
How to change the emotions you want to change in order to decrease negative vulnerabilities, reduce distress and increase “positive” emotions.
These skills will be reinforced through repetition, homework and repeated sessions between sessions. They are not specific to borderline personality disorder.
They can also be adapted for bipolar disorder or adolescents. They build a set of psychological skills for a healthy and balanced lifestyle.