Borderline Personality Disorder (BPD) is one of the most controversial diagnoses in psychology today and is a personality disorder described as a prolonged disturbance of personality function characterized by depth and variability of moods. The disorder typically involves unusual levels of instability in mood; “black and white” thinking, chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual’s sence of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation. These disturbances can have a pervasive negative impact on many or all of the psychosocial facets of life. This includes difficulties maintaining relationships in work, home and social settings. Attempted suicide and completed suicide are possible outcomes, especially without proper care and effective therapy.
As with other mental disorders, the causes of BPD are complex and unknown. One finding is a history of childhood trauma, abuse or neglect, although researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors, or brain abnormalities. At least one researcher believes BPD results from a combination that can involve a traumatic childhood, a vulnerable temperament and stressful maturational events during adolescence or adulthood. The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population, with approximately 75 percent of those diagnosed being female. It has been found to account for 20 percent of psychiatric hospitalizations. The mainstay of treatment is various forms of psychotherapy, although medication and other approaches may also improve symptoms.
Management
Psychotherapy is one form of management. There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with BPD can benefit on at least some outcome measures. Supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD. Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD, though drop-out rates may be problematic. A new study has attempted to devise a method for reducing drop-out rates, as well as maintaining the motivation of the therapist, pointing out that treatment of this “difficult group” of people with BPD (especially with suicidal tendencies) can be difficult on the therapist and can contribute to treatment failures and drop-out rates. The devised method has been named Dialectical behavior therapy.
Medication is another form of management. The UK’s National Institute for Health and Clinical Excellence (NICE) in 2009 recommends against the use of medication for treating borderline personality disorder and that they should only be considered for comorbid conditions. A Cochrane review from 2006 arrived at the same conclusion. Antidepressants, Antipsychotics and Mood stabilisers (such as lithium) are regularly used to treat co-morbid symptoms such as depression.
Individuals with BPD sometimes use mental health services extensively. People with this diagnosis accounted for about 20 percent of psychiatric hospitalizations in one survey. The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time. Experience of services varies. Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviors) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.
Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups. On the other hand, those with the diagnosis of BPD have reported that the term “BPD” felt like apejorative label rather than a helpful diagnosis, that self-destructive behaviour was incorrectly perceived as manipulative, and that they had limited access to care. Attempts are made to improve public and staff attitudes.
The features of BPD include emotional instability, intense unstable interpersonal relationships, a need for relatedness and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms such as “difficult,” “treatment resistant,” “manipulative,” “demanding” and “attention seeking” are often used, and may become a self-fulfilling prophecy as the clinician’s negative response triggers further self-destructive behavior. In psychoanalytic theory, this stigmatization may be thought to reflect “counter transference” (when a therapist projects their own feelings on to a client), as people with BPD are prone to use defense mechanisms such as splitting and projective identification. Thus the diagnosis “often says more about the clinician’s negative reaction to the patient than it does about the patient … as an expression of counter transference hate, borderline explains away the breakdown in empathy between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon”.
This inadvertent counter transference can give rise to inappropriate clinical responses including excessive use of medication, inappropriate mothering and punitive use of limit setting and interpretation. People with BPD are seen as among the most challenging groups of patients, requiring a high degree of skill and training in the psychiatrists, therapists and nurses involved in their treatment. People labeled with “Borderline Personality Disorder” often feel it is unhelpful and stigmatizing as well as simply inaccurate, supporting and adding to calls for a name change.