
                        Borderline Personality Disorder
                                       
   Borderline Personality Disorder (BPD) is one of the most controversial
   diagnoses in psychology today. Since it was first introduced in the
   DSM, psychologists and psychiatrists have been trying to give the
   somewhat amorphous concepts behind BPD a concrete form. Kernberg's
   explication of what he calls [1]Borderline Personality Organization is
   the most general, while [2]Gunderson, though a psychoanalyst, is
   considered by many to have taken the most scientific approach to
   defining BPD. The Diagnostic Interview for Borderlines and the
   [3]DIB-Revised were developed from research done by Gunderson, Kolb,
   and Zanarini. Finally, there is the "official" [4]DSM-IV definition.
   
   Some researchers, like Judith Herman, believe that BPD is a name given
   to a particular manifestation of post-traumatic stress disorder: in
   Trauma and Recovery, she theorizes that when PTSD takes a form that
   emphasizes heavily its elements of identity and relationship
   disturbance, it gets called BPD; when the somatic (body) elements are
   emphasized, it gets called hysteria, and when the
   dissociative/deformation of consciousness elements are the focus, it
   gets called DID/MPD. Others believe that the term "borderline
   personality" has been so misunderstood and misused that trying to
   refine it is pointless and suggest instead simply scrapping the term.
   
What causes Borderline Personality Disorder?

   It would be remiss to discuss BPD without including a comment about
   Linehan's work. In contrast to the symptom list approaches detailed
   below, Linehan has developed a comprehensive sociobiological theory
   which appears to be borne out by the successes found in controlled
   studies of her Dialectical Behavioral Therapy.
   
   Linehan theorizes that borderlines are born with an innate biological
   tendency to react more intensely to lower levels of stress than others
   and to take longer to recover. They peak "higher" emotionally on less
   provocation and take longer coming down. In addition, they were raised
   in environments in which their beliefs about themselves and their
   environment were continually devalued and invalidated. These factors
   combine to create adults who are uncertain of the truth of their own
   feelings and who are confronted by three basic dialectics they have
   failed to master (and thus rush frantically from pole to pole of):
     * vulnerability vs invalidation
     * active passivity (tendency to be passive when confronted with a
       problem and actively seek a rescuer) vs apparent competence
       (appearing to be capable when in reality internally things are
       falling apart)
     * unremitting crises vs inhibited grief.
       
   [5]DBT tries to teach clients to balance these by giving them training
   in skills of mindfulness, interpersonal effectiveness, distress
   tolerance, and emotional regulation.
   
Kernberg's Borderline Personality Organization

   Diagnoses of BPO are based on three categories of criteria. The first,
   and most important, category, comprises two signs:
   
     * the absence of psychosis (i.e., the ability to perceive reality
       accurately)
     * impaired ego integration - a diffuse and internally contradictory
       concept of self. Kernberg is quoted as saying, "Borderlines can
       describe themselves for five hours without your getting a
       realistic picture of what they're like."
       
   The second category is termed "nonspecific signs" and includes such
   things as low anxiety tolerance, poor impulse control, and an
   undeveloped or poor ability to enjoy work or hobbies in a meaningful
   way.
   
   Kernberg believes that borderlines are distinguished from neurotics by
   the presence of "primitive defenses." Chief among these is splitting,
   in which a person or thing is seen as all good or all bad. Note that
   something which is all good one day can be all bad the next, which is
   related to another symptom: borderlines have problems with object
   constancy in people -- they read each action of people in their lives
   as if there were no prior context; they don't have a sense of
   continuity and consistency about people and things in their lives.
   They have a hard time experiencing an absent loved one as a loving
   presence in their minds. They also have difficulty seeing all of the
   actions taken by a person over a period of time as part of an
   integrated whole, and tend instead to analyze individual actions in an
   attempt to divine their individual meanings. People are defined by how
   they lasted interacted with the borderline.
   
   Other primitive defenses cited include magical thinking (beliefs that
   thoughts can cause events), omnipotence, projection of unpleasant
   characteristics in the self onto others and projective identification,
   a process where the borderline tries to elicit in others the feelings
   s/he is having. Kernberg also includes as signs of BPO chaotic,
   extreme relationships with others; an inability to retain the soothing
   memory of a loved one; transient psychotic episodes; denial; and
   emotional amnesia. About the last, Linehan says, "Borderline
   individuals are so completely in each mood, they have great difficulty
   conceptualizing, remembering what it's like to be in another mood."
   
Gunderson's conception of BPD

   Gunderson, a psychoanalyst, is respected by researchers in many
   diverse areas of psychology and psychiatry. His focus tends to be on
   the differential diagnosis of Borderline Personality Disorder, and
   Cauwels gives Gunderson's criteria in order of their importance:
     * Intense unstable relationships in which the borderline always ends
       up getting hurt. Gunderson admits that this symptom is somewhat
       general, but considers it so central to BPD that he says he would
       hesitate to diagnose a patient as BPD without its presence.
     * Repetitive self-destructive behavior, often designed to prompt
       rescue.
     * Chronic fear of abandonment and panic when forced to be alone.
     * Distorted thoughts/perceptions, particularly in terms of
       relationships and interactions with others.
     * Hypersensitivity, meaning an unusual sensitivity to nonverbal
       communication. Gunderson notes that this can be confused with
       distortion if practitioners are not careful (somewhat similar to
       Herman's statement that, while survivors of intense long-term
       trauma may have unrealistic notions of the power realities of the
       situation they were in, their notions are likely to be closer to
       reality than the therapist might think).
     * Impulsive behaviors that often embarrass the borderline later.
     * Poor social adaptation: in a way, borderlines tend not to know or
       understand the rules regarding performance in job and academic
       settings.
       
The Diagnostic Interview for Borderlines, Revised

   Gunderson and his colleague, Jonathan Kolb, tried to make the
   diagnosis of BPD by constructing a clinical interview to assess
   borderline characteristics in patients. The DIB was revised in 1989 to
   sharpen its ability to differentiate between BPD and other personality
   disorders. It considers symptoms that fall under four main headings:
    1. Affect
          + chronic/major depression
          + helplessness
          + hopelessness
          + worthlessness
          + guilt
          + anger (including frequent expressions of anger)
          + anxiety
          + loneliness
          + boredom
          + emptiness
    2. Cognition
          + odd thinking
          + unusual perceptions
          + nondelusional paranoia
          + quasipsychosis
    3. Impulse action patterns
          + substance abuse/dependence
          + sexual deviance
          + manipulative suicide gestures
          + other impulsive behaviors
    4. Interpersonal relationships
          + intolerance of aloneness
          + abandonment, engulfment, annihilation fears
          + counterdependency
          + stormy relationships
          + manipulativeness
          + dependency
          + devaluation
          + masochism/sadism
          + demandingness
          + entitlement
       
   The DIB-R is the most influential and best-known "test" for diagnosing
   BPD. Use of it has led researchers to identify four behavior patterns
   they consider peculiar to BPD: abandonment, engulfment, annihilation
   fears; demandingness and entitlement; treatment regressions; and
   ability to arouse inappropriately close or hostile treatment
   relationships.
   
DSM-IV criteria

   The DSM-IV gives these nine criteria; a diagnosis requires that the
   subject present with at least five of these. In I Hate You -- Don't
   Leave Me! Jerold Kriesman and Hal Straus refer to BPD as "emotional
   hemophilia; [a borderline] lacks the clotting mechanism needed to
   moderate his spurts of feeling. Stimulate a passion, and the
   borderline emotionally bleeds to death."
   
  Traits involving emotions:
  
   Quite frequently people with BPD have a very hard time controlling
   their emotions. They may feel ruled by them. One researcher (Marsha
   Linehan) said, "People with BPD are like people with third degree
   burns over 90% of their bodies. Lacking emotional skin, they feel
   agony at the slightest touch or movement."
   
   1. Shifts in mood lasting only a few hours.
   
   2. Anger that is inappropriate, intense or uncontrollable.
   
  Traits involving behavior:
  
   3. Self-destructive acts, such as self-mutilation or suicidal threats
   and gestures that happen more than once
   
   4. Two potentially self-damaging impulsive behaviors. These could
   include alcohol and other drug abuse, compulsive spending, gambling,
   eating disorders, shoplifting, reckless driving, compulsive sexual
   behavior.
   
  Traits involving identity
  
   5. Marked, persistent identity disturbance shown by uncertainty in at
   least two areas. These areas can include self-image, sexual
   orientation, career choice or other long-term goals, friendships,
   values. People with BPD may not feel like they know who they are, or
   what they think, or what their opinions are, or what religion they
   should be. Instead, they may try to be what they think other people
   want them to be. Someone with BPD said, "I have a hard time figuring
   out my personality. I tend to be whomever I'm with."
   
   6. Chronic feelings of emptiness or boredom. Someone with BPD said, "I
   remember describing the feeling of having a deep hole in my stomach.
   An emptiness that I didn't know how to fill. My therapist told me that
   was from almost a "lack of a life". The more things you get into your
   life, the more relationships you get involved in, all of that fills
   that hole. As a borderline, I had no life. There were times when I
   couldn't stay in the same room with other people. It almost felt like
   what I think a panic attack would feel like."
   
  Traits involving relationships
  
   7. Unstable, chaotic intense relationships characterized by splitting
   (see below).
   
   8. Frantic efforts to avoid real or imagined abandonment
     * Splitting: the self and others are viewed as "all good" or "all
       bad." Someone with BPD said, "One day I would think my doctor was
       the best and I loved her, but if she challenged me in any way I
       hated her. There was no middle ground as in like. In my world,
       people were either the best or the worst. I couldn't understand
       the concept of middle ground."
     * Alternating clinging and distancing behaviors (I Hate You, Don't
       Leave Me). Sometimes you want to be close to someone. But when you
       get close it feels TOO close and you feel like you have to get
       some space. This happens often.
     * Great difficulty trusting people and themselves. Early trust may
       have been shattered by people who were close to you.
     * Sensitivity to criticism or rejection.
     * Feeling of "needing" someone else to survive
     * Heavy need for affection and reassurance
     * Some people with BPD may have an unusually high degree of
       interpersonal sensitivity, insight and empathy
       
   9. Transient, stress-related paranoid ideation or severe dissociative
   symptoms
   
   This means feeling "out of it," or not being able to remember what you
   said or did. This mostly happens in times of severe stress.
   
Miscellaneous attributes of people with BPD:

     * People with BPD are often bright, witty, funny, life of the party.
     * They may have problems with object constancy. When a person leaves
       (even temporarily), they may have a problem recreating or
       remembering feelings of love that were present between themselves
       and the other. Often, BPD patients want to keep something
       belonging to the loved one around during separations.
     * They frequently have difficulty tolerating aloneness, even for
       short periods of time.
     * Their lives may be a chaotic landscape of job losses, interrupted
       educational pursuits, broken engagements, hospitalizations.
     * Many have a background of childhood physical, sexual, or emotional
       abuse or physical/emotional neglect.
       
   [INLINE]
   
   [INLINE]
   
  go to [6]list of BPD treatment programs
  
  return to [7]SI main page

References

   1. file://localhost/usr/home/llama/Web/psych/bdp.html#kern
   2. file://localhost/usr/home/llama/Web/psych/bdp.html#gund
   3. file://localhost/usr/home/llama/Web/psych/bdp.html#dibr
   4. file://localhost/usr/home/llama/Web/psych/bdp.html#dsmiv
   5. file://localhost/usr/home/llama/Web/psych/dbt.html
   6. file://localhost/usr/home/llama/Web/psych/programs.html
   7. file://localhost/usr/home/llama/Web/psych/injury.html
