Borderline Personality Disorder: what is it?

WexlerPsychiatryWinterBy Dr. Micaela Wexler

The following three fictionalized cases are examples of women with Borderline Personality Disorder.

Carol (not her real name) is 29 years old. She was brought to the emergency room by police after they were called by her girlfriend when Carol threatened to kill herself with a butter knife. This is Carol’s fourth time in the emergency room in the past year for suicidal behavior. Carol and her girlfriend had been fighting over “nothing” and when her girlfriend tried to leave the apartment, Carol became frightened, and at that moment she really did want to “just die.” This is not the first time Carol has done this to this girlfriend. Carol tells me she does things to push her girlfriend away, and then when her girlfriend responds, Carol becomes frightened, because she is afraid of being alone. Carol’s girlfriend tells me that when they are not fighting, they get along extremely well. Carol is fun, witty, spontaneous, and is very bright, which makes this behavior very puzzling to her girlfriend. Both Carol and her girlfriend tell me that Carol’s emotions “change at the drop of a hat.” On the day she was seen in the emergency room, Carol had been very happy, and suddenly flew into a rage when her girlfriend questioned some charges on the credit card Carol had borrowed to get gas. Carol had stopped to buy her girlfriend a “present,” a new pair of boots she felt her girlfriend needed for the snow and would not take the time to buy for herself. At the time she bought the boots, a month ago, her girlfriend had expressed gratitude, and, in fact, she was wearing those same boots in the emergency room. Carol had meant to tell her eventually that the boots had been charged on her girlfriend’s credit card, but had put it off, not wanting to ruin the moment. “I was afraid she would get angry at me for that and just dump me, and here she is, about to do exactly what I was afraid of.”

Cheryl (also not her real name) is 28 years old. She has three children under the age of five from three different relationships, and they were all taken into state custody after Cheryl had a string of admissions to the inpatient psychiatry unit for suicidal behavior and self-injurious behavior. These admissions all occurred following Cheryl’s break-ups with different men. She has a history of putting men she meets on a pedestal, and then breaking up with them when she either perceives a flaw, or discovers a genuine problem, such as a drug history or criminal history. In the past four months, Cheryl has had three break-ups, and the last one was violent because the man didn’t want to break up (and find another place to live), and led to Cheryl losing custody of her children. Cheryl’s pattern is the following: she meets a man, and idealizes him. She tells me, “this is the one,” and I hear her fantasizing about the wonderful life she and her children are now going to have because she finally met a really nice guy who “treats me like a queen.” Whenever I ask Cheryl to describe what she means when she says she is treated like a queen, she describes what to me sound like mundane actions: he bought her dinner once; he didn’t leave while she was still asleep, he filled her car up with gas when they used it to go out, he was nice to the kids, he didn’t complain when her babysitter cancelled at the last minute. Usually, Cheryl idealizes these men so quickly she doesn’t take time to get to know them very well. This puts her and her children in jeopardy. When she discovers they are spending the night because they are hiding from their meth dealer, or from the police, she feels genuinely betrayed. When she is forced to break up with them, Cheryl is left with feelings of emptiness alternating with feelings of despair. To cope with her feelings she cuts herself or bangs her head into the wall until she passes out.

Cindy (definitely not her real name) is 33 years old. She has been married for 8 years, and she and her husband have three children. She is employed full time, and is active in her church. When I first met her in clinic, she was wanting to be evaluated for Adult ADHD. She had just gone back to school part time, with plans to become a surgical nurse, and possibly “going all the way to becoming a nurse practitioner.” She was almost euphoric with excitement about her new plan. She presented to her next visit a month later in tears over her news that she had discovered her husband was being unfaithful and they would probably divorce. I advised her to get into therapy, and refilled her medications. At the next visit two months later, not a word was mentioned about either the divorce or school, something I didn’t notice until after she had left, because she had presented in a rage as she described an altercation she had at work with a fellow employee. She reported, “it might have gotten physical, I don’t know because I blacked out. They were going to try to send me to the unit, but [the other employee] is my brother-in-law’s cousin, and so we settled our fight before they could do that.” Cindy confessed to me that every few months, she will have a “huge drag out fight” with someone at work because “I don’t know how to say no, and then they just walk all over me and I snap.”

Each of these patients was evaluated further over the months, and they each met criteria for Borderline Personality Disorder. The disorder occurs by early adulthood. There is a pervasive pattern of unstable interpersonal relationships. They also have marked impulsivity, seen in different settings. They complain of emotions that are out of control with rapid mood swings and are sometimes mistakenly diagnosed with Bipolar Mood Disorder.

To meet criteria, the person has to have five or more of the following:

• Frantic efforts to avoid real or imagined abandonment expressed by becoming emotionally unstable when they PERCIEVE someone might be breaking up
• A pattern of unstable and intense interpersonal relationships
• Identity disturbance expressed by very low self-esteem
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• Emotional instability due to significant reactivity of mood (e.g., intense sudden episodic depression, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• Transient, stress-related paranoid thoughts or severe dissociative symptoms

How is Borderline Personality Disorder Diagnosed?

Borderline personality disorder is typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians, internists, some counselors and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. People outside of the health professions are not at all qualified to make this diagnoses. A person must be over the age of 18 to be diagnosed.

Most people with Borderline Personality Disorder suffer for years without a diagnoses or treatment, and it usually takes a crisis, such as those listed in the examples above, for the person with Borderline Personality Disorder to get identified.

Causes of Borderline Personality Disorder

At this time, the exact cause is not known. However, the theories which have the most support are those that subscribe to a biopsychosocial model of causation — that is, the causes of are likely due biological and genetic factors, social factors, and psychological factors. In other words, the nervous system a person was born with can put them at risk. People with BPD have bound found to have larger amygdalas than those without BPD. How a person was treated by their family in their early years seems to have a great influence. For example, people who were sexually abused as young children have a significantly higher rate of Borderline Personality Disorder than other people. Also, a person’s temperament, which is also influenced by the manner in which they were treated as children, can also put them at risk. Children whose feelings are invalidated, ie, a child cries and is told, “stop crying,” or “you’re okay, you’re not sad,” are at higher risk of developing Borderline Personality Disorder. Also, children who are emotionally abused or neglected have a higher rate of Borderline Personality Disorder as adults.

Treatment of Borderline Personality Disorder

Long term psychotherapy in the outpatient setting is the treatment of choice for Borderline Personality Disorder. There is a type of psychotherapy developed SPECIFICALLY for Borderline Personality Disorder by Dr. Marsha Linehan called Dialectal behavior therapy (DBT). This is the most widely used successful treatment for Borderline Personality Disorder. Dr. Linehan is a well known and respected psychologist on the faculty at the University of Washington, and she recently began to speak publicly about her own struggles during her early adulthood with Borderline Personality Disorder. By her own reports, she was a “cutter,” cutting herself excessively until she was finally treated.

Dialectical Behavior Therapy is a long term, intense therapy program, with both individual therapy and group therapy components. Clients (they are not referred to as patients) are given homework, and are taught skills to identify their emotions and to cope with their interpersonal relationships. Remaining in the outpatient setting, ie, not going to the hospital, is an important goal of treatment, and meeting this goal improves the prognosis for people with Borderline Personality Disorder.

Dr. Linehan has developed a web site,, outlining the rigorous qualifications therapists need to fulfill in order to be qualified to provide Dialectical Behavior Therapy.

Although Dialectical Behavior Therapy is the most widely used successful therapy, there is another therapy that has provided some results, and is often available in places that do not provide DBT. It is called General Psychiatric Management for Borderline Personality Disorder. As found in the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder, it is described in the following way: “this coherent, high-standard outpatient treatment consists of case management, dynamically informed psychotherapy, and symptom-targeted medication management. Pharmacotherapy was based on the symptom-targeted approach but prioritized treatment of mood lability, impulsivity, and aggressiveness, as presented in the APA guideline.” This type of therapy requires a psychiatrist (a medical doctor). Although it is not as successful as DBT, it has been shown through research to offer some relief, and result in decreasing suicidal behavior.

For more information about Borderline Personality Disorder, click here. – Child and Adolescent Psychiatry blog

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