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Section 1
A Review of Borderline Personality Disorder

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I feel a good place to start with this section is to cover the basics regarding Borderline Personality Disorder to make sure we are all on the same page, so to speak.

Borderline Personality Disorder is a severe, chronic, disabling, and potentially lethal psychiatric condition. People who suffer with this disorder have extreme and long standing instability in their emotional lives, as well as in their behavior and their self-image. This is a common disorder affecting 2% of the general population. The best evidence indicates that about 11% of psychiatric outpatients and 19% of inpatients meet diagnostic criteria for BPD.

♦ Neurotic and Psychotic Characteristics
As you know, Borderline Personality Disorder was once associated with schizophrenia. Stern was the first to coin the term "borderline" to describe a specific pathological condition that he thought had both neurotic and psychotic characteristics. Thus in my opinion, I like to think of a client with BPD as being on the borderline between neurosis and psychosis. However, in the past decade, as you know, BPD has been detached from that disorder to be associated with affective disorders.

For the Borderline Personality Disordered client, relationships with others are intense, stormy, and unstable with marked shifts of feelings and difficulties in maintaining intimate, close connections. The person may manipulate others and often has difficulty with trusting others. There is also emotional instability, with marked and frequent shifts, to an empty lonely depression or to irritability and anxiety. All too frequently, 69% to 75% of individuals with BPD resort to self-destructive behaviors.

There may be unpredictable and impulsive behavior which might include excessive spending, promiscuity, gambling, drug or alcohol abuse, shoplifting, overeating or physically self-damaging actions such as suicidal gestures.

♦ Anger and Deep-Seated Feelings or Beliefs
The client with BPD may show inappropriate and intense anger or rage with temper tantrums, constant brooding and resentment, feelings of deprivation, and a loss of control or fear of loss of control over angry feelings. The client with BPD also may display identity disturbances with confusion and uncertainty about self-identity, sexuality, life goals and values, career choices, friendships. Do you agree?

For your client with BPD there is a deep-seated feeling that he or she is flawed, defective, damaged or bad in some way, with a tendency to go to extremes in thinking, feeling or certain behaviors. Under extreme stress or in severe cases there can be brief psychotic episodes with loss of contact with reality or bizarre behavior or symptoms. Even in less severe instances, there is often significant disruption of relationships and work performance. The sections that follow this will discuss Susan and her rocky relationship with her husband Dan.

The depression which accompanies this disorder can cause much suffering and can lead to serious suicide attempts. The completed suicide rate for BPD individuals is 3% to 9.5% (McGlashan, 1986; Stone,1983), which is comparable to the other serious psychiatric disorders such as depression, alcohol dependence, and schizophrenia.

♦ 5 Treatment Goals
Treatment goals can include:
-- 1. increased self-awareness,
-- 2. greater impulse control, and
-- 3. increased stability of relationships.
-- 4. A positive treatment result for Susan, as you will see, was increased tolerance of anxiety.
-- 5. As you know, a general therapy goal is to alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality.
With this increased awareness, and capacity for self-observation and introspection, it is hoped the patient will be able to change their rigid patterns, tragically set earlier in life and prevent the pattern from repeating themselves in the next generational cycle.

♦ Treatment Difficulties
Compounding the seriousness of Borderline Personality Disorder , as you know, it is difficult to treat. The very characteristics of the disorder, such as unstable relationships and intense anger, interfere with establishing the therapeutic relationship that is necessary to any treatment, whether psychotherapy or medication. Are you reluctant to treat these individuals because they exhibit two characteristics likely to lead to clinician " burnout " the BPD person's hostility towards the clinical professional and their persistent suicidal thoughts and feelings ?

I believe that if there is in fact a rise of Borderline Personality Disorder in our culture, it is related to the interplay between child-rearing practices and the effects of social structures that come into play during early adolescence and young adulthood.

♦ 3 Underlying Cause Models for BPD
According to Paris, there are three etiologic or underlying cause models for Borderline Personality Disorder.
1. Brain Injury: One possibility is brain injury. For example, damage to the orbital frontal cortex and other limbic sites could skew impulse control, affective dysregulation, cognitive disability, and predisposition to psychotic decompensation.
2. The Surrounding Environment: Another trigger or underlying cause for BPD is the influences of a client's surrounding environment. Parents, for example, who suffer from developmental disturbances, expose their children to aberrant behaviors such as alcohol abuse, promiscuity, marital discord, and abuse. As you are aware, these behaviors can severely damage a client during behavioral development.
3. Impulse Control: In addition to brain injury and environment an underlying cause of BPD is a primary disorder of impulse control. This leaves a client at a higher risk for traumatic brain damage and substance abuse. This exacerbates the impulse control disorder, worsening the client's condition.

According to Gunderson and Elliott, in a subgroup of clients, traumatic brain injury or other CNS illness occurs in the absence of preexisting impulse control disorder and is the primary cause of impulsivity in BPD clients.

♦ Exploring Connections between MAD and BPD
Gunderson and Elliott report that there is a 40-60% overlap with major affective disorder (MAD) and BPD. Others hold that BPD is only a form of MAD and not a separate entity. What do you think? Does BPD have a separate identity from MAD or a major affective disorder?

Those that hold this theory point to the fact that the many detrimental behaviors of a BPD client such as suicide attempts, poor object relations, and sexual promiscuity are ways to cope with such emotions as, despair, poor self-esteem, and efforts to alleviate depression.

In several cases of BPD with MAD, the borderline symptoms seemed to remit with the remission of affective symptoms. This suggests that for some of the BPD patients with concurrent MAD, the symptoms of BPD may have been secondary to the affective disorder.

However, Kernberg suggests that affective illness develops as a result of a BPD client's failed relationships, impulsive behavior, and hypersensitivity to separation and loss.

Finally, one theory stipulates that affective illness and BPD have no relation and only coincidentally occur simultaneously.

Alternatively, it could be argued that this relationship represents a way of dealing with emotional pain in a motoric fashion. Also, borderline patients use impulsivity as a means of self-soothing as well as a way to express their desperation, rage, and intense frustration. Ultimately, it may well turn out that both are true.

In this section, we discussed definitions, symptoms, and treatment challenges regarding your client who has a Borderline Personality Disorder.

In the next section, we will examine how schemas affect everyday lives: as a way to view the world; and a stored response to an emotional trauma. Also, we addressed various maladaptive schemas that characterize many BPD clients: selective perception, overgeneralization, and jumping to conclusions.
Reviewed 2023

Peer-Reviewed Journal Article References:
Boylan, K., Chahal, J., Courtney, D. B., Sharp, C., & Bennett, K. (2019). An evaluation of clinical practice guidelines for self-harm in adolescents: The role of borderline personality pathology. Personality Disorders: Theory, Research, and Treatment, 10(6), 500–510.

Cavicchioli, M., & Maffei, C. (2020). Rejection sensitivity in borderline personality disorder and the cognitive–affective personality system: A meta-analytic review. Personality Disorders: Theory, Research, and Treatment, 11(1), 1–12.

Conway, C. C., Hopwood, C. J., Morey, L. C., & Skodol, A. E. (2018). Borderline personality disorder is equally trait-like and state-like over ten years in adult psychiatric patients. Journal of Abnormal Psychology, 127(6), 590–601.

Crowell, S. E., & Kaufman, E. A. (2016). Borderline personality disorder and the emerging field of developmental neuroscience. Personality Disorders: Theory, Research, and Treatment, 7(4), 324–333.

MacIntosh, H. B., Godbout, N., & Dubash, N. (2015). Borderline personality disorder: Disorder of trauma or personality, a review of the empirical literature. Canadian Psychology/Psychologie canadienne, 56(2), 227–241. 

QUESTION 1
What disorder might be linked with Borderline Personality Disorder? To select and enter your answer, go to Test.

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