Some of you have already heard of Borderline Personality Disorder (BPD). But, if you haven’t, you’ll connect quickly to the seriousness of this disorder by the dramatic films that portray this type of personality, like Girl Interrupted (Winona Ryder and Angelina Jolie), Single, White Female (Jennifer Jason Leigh), and Sleeping With the Enemy (Julia Roberts).

Although Hollywood’s rendition of BPD is quite extreme, you can find examples of these more dramatic, dangerous borderline persons in real life.  Some of them are capable of carrying out a grudge far beyond most of us could ever imagine. I’m sure many of you know of the infamous La Jolla, California socialite Betty Broderick (1989) who, in a fit of rage, killed her ex-husband and lawyer, Dan Broderick III and his new young wife Linda Cohenia. This story of borderline abandonment and revenge captured Hollywood’s attention (Betty Broderick: A Woman Scorned, with Meredith Baxter). It is such a popular television movie that Lifetime TV is still running it 20 years after Broderick killed her ex-husband.

There is also Jodi Arias who is on trial right now for repeatedly stabbing (30 times), almost decapitating, and then shooting her cheating lover. From what I know of the case thus far, Arias appears to fit the criteria for the more dangerous type of BPD. And, I’m sure Arias’ story will soon make its ways into Hollywood too, as we are ever fascinated by people who act out their impulses murderously.

But, unlike the infamous borderlines in the news, most borderline people harm themselves, rather than hurt other people. There are many contributing factors to the borderline personality condition (biology, early developmental experiences, and other personality features, like narcissism and antisocial impulses) that creates differences between borderline people. The weight of one factor over another can determine the extent of the borderline pathology and treatment outcome.

But, before I go further in helping you to understand BPD, let’s consider why these types of personality are called borderline in the first place.

Why Borderline?

Psychiatry called this disorder BPD, because these persons function somewhere in between a state of neurosis and psychoticism. They are not obviously crazy. But, they are dictated mostly by inner impulses, which makes their behavior fantasy-based, self-centered, and, at times, antisocial.

Nonetheless, the line between the real world and their inner processes is a fragile one, indeed. This is because borderline persons have limited to no ability to use the executive area of the brain (Frontal Lobes) to consider the effect of their impulses on themselves and other people. They are limited greatly in the ability to self-govern themselves through mental processes, so that they rarely reflect upon, learn from, or give meaning to experience that can grow them. They have what is clinically referred to as a fragile, immature ego, which is essentially to say that the capacities of the brain’s frontal lobes are insufficiently developed.

Their fragile ego is also why they have great difficulty defusing powerful emotions of hurt, sadness, and anger through reasoned thinking. Thus, their reactions are often self-centered, destructive, and out of control, which can lead them to threaten harm to themselves or to other people. It’s no wonder that people experience them as self-indulgent. And, only adding to the perception that they are self-absorbed is their inability to consider how their behavior impacts other people. But, their lack of empathy is less from self-preoccupation than it is from an inability to reflect upon other persons’ frustration and pain (See Mirror Neuron Explanation in Article: Can You Strengthen The Empathy Muscle).

If you have a friend or family member who has such difficulties, you know too well the affect of their self-indulgence on them and you. But, unless, you are clinically trained, you may think that their self-destructive behaviors are just to spite you and to resist growing up, rather than an expression of their inability to learn from experience.

Hallmarks of BPD

Early development plays a strong role in the making of a borderline personality. Either through neglect or spoiling of the child, caretakers did not provide sufficient teaching experiences for the child to learn how to regulate his or her impulses and emotions. Hence, the child’s intense needs overwhelm their ability to think through, reason and learn from experience, which frustrates their psychological growth. They experience each situation as new, with little to no connection to the past, and no anticipation of what their behavior means to their future functioning. They fluctuate between feeling bored, empty, and deprived, or highly anxious – craving excitement, attention, and emotional connection to quell this yearning. Food, drugs, alcohol, or even cutting on themselves are ways to allay the unbearable anxiety that they feel, at such times.

Sadly, this vicious cycle of need fulfillment stops them from learning how to cope with life’s problems on their own. They require things outside of themselves to soothe their frustrations, just like young children do. Only, instead of running to mommy for help and comfort, they turn to substances, risky people and activities, and self-injurious cutting on themselves, to calm down. These comforting agents are a life source to the borderline person, like a mother is to a young child. Without them, they feel afraid, empty, and abandoned. Can you imagine just how difficult it is to free a borderline person of people and activities that they view as a life source? It’s like taking a young child away from his or her mother.

BPD In Treatment

It’s critical that the treating therapist assesses accurately all of the contributing factors that are preventing the borderline person from learning through experience, as the main therapy challenge is to get the patient to use his or her frontal lobes to process what happens to them. This can be a challenging, lengthy, and frustrating task of having to reparent the borderline person. The therapist has to essentially connect up the borderline person’s inner world with outer reality. We become the patient’s frontal lobes until theirs are strong enough to take over. And, like a good parent, the therapist must be empathic, patient, and signed up to treat the patient for the long haul (at the least, two to five years). As I said, the good news is that borderline people can learn and grow, especially as they mature with age.

Nonetheless, borderline people are difficult to treat. It’s not easy to loosen them from destructive people and activities that soothe their anxiety and frustrations. The therapist must become the soothing agent, so that these destructive sources lose their appeal.

Additionally, as many as 75% of borderline persons hurt themselves and approximately 10% will commit suicide. This is an extraordinarily high suicide rate, by comparison to the 6% suicide rate for mood disorders (Borderline Personality Disorder: Mental Illness on the Rise? Time Magazine). Thus, therapists have to be continually alert to the risk of suicide in such patients.

As you can see, treating a borderline condition is no easy task and requires a special course of treatment to serve the patient well. Many people are wrongly diagnosed either because of the therapist’s lack of skill and knowledge in diagnosis or the patient’s underlying pathology is hidden until uncovered by therapy. This is unfortunate, as there’s nothing worse for the therapist and the patient than missing the risk of suicide.

The recent revision of the Diagnostic Statistical Manual of Psychiatric Behavior from its 4th to 5th edition made radical changes in the diagnosis of personality disorders, to avoid misdiagnosis as much as possible. Now, for a BPD diagnosis to be made, there has to be significant impairments in identity, self-direction, empathy and intimate relations and also the presence of emotional lability, anxiousness, separation fears, impulsivity, risk-taking and hostility. Additionally, the impairments of personality development and functioning must be stable over time, not due to stage of development or social and cultural influences, or solely due to drug or medication use (DSM V).

I’m glad for this attempt to refine the diagnostic process, so that there’s less chance of misdiagnosis and so that the public is better served. The more serious personality types, like the avoidant, borderline and narcissistic personality disorders can be a hard pill to swallow for those people who are receiving the diagnosis. Thus, it is so important to understand the great variability within the group of people who are given a specific diagnosis. And, that it is the level of the symptoms that heighten the probability of having a personality disorder.

The abstract features of a diagnosis do not say much about the concrete strengths and weaknesses of the person you are thinking about. I have treated several borderline people throughout the years. Their weaknesses can also be their strengths. They are often highly creative, intuitively sensitive, and intelligent and capable of bonding to people. With the proper diagnosis, treatment, and therapist, there is much possibility of them maturing and leading productive and happy lives.

I hope you liked today’s post. If you did, please let me know by selecting the Like icon that immediately follows. You can also Tweet or Google+1 this post to let others know about it. Warm regards to you, Deborah.