“Borderline individuals are the psychological equivalent of third-degree-burn patients.  They simply have, so to speak, no emotional skin.  Even the slightest touch or movement can create immense suffering.” – Marsha Linehan, Ph.D.

Borderline Personality Disorder (BPD) is a serious mental illness distinguished by persistent instability in mood, behavior, interpersonal relationships, and self-image.  This instability disrupts family, social, school, and work life, as well as long-term planning.  Originally thought to be at the “borderline” of psychosis, what makes BPD so explosive is the sufferers’ dramatic inability to regulate their feelings and behaviors.  When confronted with an experience that makes them sad or angry they can often become inconsolable or enraged.  They seem to have no internal emotion regulator as they are capable of extreme depths of love and overwhelming rage almost simultaneously.  They are intensely connected to the people close to them, and yet at the same time utterly terrified by the possibility of losing them.  Nevertheless, out of the blue they will lay into those very people oftentimes ensuring the very abandonment they so fear.  In Borderline Personality Disorder it is not only the presence of this frank mood instability, but also present is notable “black and white” thinking or “splitting” – thinking purely in extremes, oftentimes switching between idealizing and demonizing others.  These individuals are often incapable of understanding or accepting the “gray” areas of normal interpersonal relationships.  It is believed this type of personality thought process stems from significant insecurities and instability in one’s concept of themselves.  Such problems may be made even worse by impulsive behaviors such as overeating or substance abuse, intentional self-injurious behavior, and suicide attempts.

While much less is known about BPD amongst the lay-public than Bipolar Disorder (Manic-Depressive illness) or Schizophrenia, which are diagnosed in approximately one percent of the population, Borderline Personality Disorder is actually more common, affecting an estimated two percent of adults, and appears to be more common in women than in men.  Regardless of gender, people in their 20’s are at higher risk for BPD than those older or younger.  Patients with BPD raise the greatest concern amongst mental health treatment professionals due to the fact they have an incredibly high rate of self-injurious behavior without suicide intent (as many as 75% harm themselves), as well as a significant rate of suicide attempts.  Borderline Personality Disorder can damage many areas of an individual’s life.  Intimate relationships, school, social activities, jobs, and self-image all can be negatively impacted. Repeated job losses and broken marriages are common. Self-injury, such as cutting or burning, is also oftentimes present in this disorder.  In fact, self-injurious behavior is one of the main diagnostic criteria.  In severe cases of BPD suicide attempts are all too often successful.  Some ten percent actually commit suicide, which is an astonishingly high rate when compared to the suicide rate for mood disorders overall of about six percent.  BPD patients often require extensive mental health services and account for approximately twenty percent of psychiatric hospitalizations.

Individuals with Borderline Personality Disorder often experience a recurring pattern of disorganization and volatility in self-image, mood, behavior and close personal relationships.  While a person with depression or Bipolar Disorder typically suffers through the same mood for weeks on end, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day.  These may be associated with episodes of impulsive aggression or self-injurious behaviors.   Relationships with others are intense, but stormy and unstable with striking shifts of feelings and difficulties in maintaining intimate, close connections.  Alterations in mental functioning and sense of self can lead to frequent changes in long-term goals, career plans, friendships and jobs.  They are often very sensitive to the way others treat them, reacting strongly to perceived criticism or insensitivity.  There is emotional volatility with significant and frequent shifts to an empty withdrawn depression, or to extreme irritability and anxiety.  Individuals with BPD are highly sensitive to rejection, reacting with anger and torment to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important individuals in their life when they are not physically present, leaving the sufferer with BPD feeling lost and alone.  The person may show inappropriate and intense anger or rage with temper tantrums, resentment, feelings of deprivation, and a loss of control, or fear of loss of control, over angry feelings.

Their self-image can change abruptly from one of being extremely positive to extremely negative.  There is often a deep-seated feeling that one is flawed, defective, or bad in some way, with an inclination to go to extremes in thinking, feeling or behavior.  They are often bright and intelligent, and can seem warm, friendly and quite competent.  Interestingly, they can often maintain this appearance for a number of years until their emotional defenses fall apart, usually around a stressful situation like the breakup of a romantic relationship or the death of a close supportive friend or parent.  Under severe stress, or in extreme cases, there can be brief psychotic episodes with an actual loss of contact with reality often accompanied by bizarre thoughts and behavior. The depression which oftentimes accompanies this disorder can lead to significant emotional pain and suffering as well as to serious suicide attempts.

Studies of individuals with Borderline Personality Disorder suggest that although they are often intensely intimate in their relationships, they are often exceedingly alert to perceived signs of rejection or not being prized enough.  They tend toward being incredibly insecure, unsure, and fearfully preoccupied with their relationships.  They have a tendency to view the world as cruel and dangerous, and then to view themselves as vulnerable, powerless, and unacceptable.  Individuals with BPD are often depicted as being deliberately manipulative and difficult.  However, looking deeply into the source of their behaviors, one often finds incredible turmoil, inner pain, defensiveness and a sense of helplessness with limited coping and communication skills.

The following list summarizes the symptoms of Borderline Personality Disorder:

• Intense emotions that wax and wane abruptly and often
• Great difficulty controlling emotions or impulses

• Feelings of emptiness and boredom
• Frequent displays of inappropriate anger which sometimes escalates into physical confrontations

• Intense but brief episodes of anxiety or depression
• Viewing the world in absolutes – in “black or white” without understanding or acceptance of “gray” areas of human behavior
• Impulsive and risky behavior
• Suicidal behavior
• Fear of being alone
• Fear of being abandoned
• Repeated crises and acts of self-injurious behavior such as overdosing or “cutting”

The onset of symptoms of Borderline Personality Disorder usually occurs during adolescence or young adulthood.  And, although most of the symptoms of this disorder diminish over time, only a small percentage of sufferers actually experience full recovery without the benefit of significant therapeutic intervention.  There is some research evidence supporting the belief that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood.

Individuals suffering from Borderline Personality Disorder are often diagnosed with other concurrent mental health conditions including:

• Depression
• Anxiety disorders
• Substance abuse
• Eating disorders
• Bipolar disorder

Although the actual causes of Borderline Personality Disorder are not definitively known, it is believed that genetic, family, and social factors all play significant roles in its occurrence.  Risk factors in the development of BPD include:

• Sexual abuse
• Disrupted family life
• Abandonment and/or rejection in childhood
• Dramatically poor communication within the family

Treatment interventions for Borderline Personality Disorder have improved significantly in recent years. Group and individual psychotherapy are partially effective for many patients.  The therapy needs to be structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways.  The goals of treatment include increased self-awareness with improved impulse control and stability of relationships.  A positive outcome would be a patient’s increased tolerance of anxiety.  Effective psychotherapy can also help to alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality.  With this increased awareness and ability for self-observation and introspection, it is hoped the patient will be able to change the rigid patterns sadly set earlier in life and prevent the pattern from repeating itself in the next generational cycle.

Dialectical Behavior Therapy (DBT) is a treatment designed specifically for individuals with self-injurious behaviors, such as self-cutting, suicidal thoughts, and suicide attempts, and was designed specifically to treat BPD.  Originally developed by Marsha Linehan, Ph.D. to treat people with Borderline Personality Disorder, DBT combines standard Cognitive-Behavioral Therapy (CBT) techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness. This technique has in fact demonstrated meaningful promise in a number of treatment studies.  Although DBT has significant potential in treating Borderline Personality Disorder the foundation of any effective intervention is the depth and consistency of the therapeutic relationship developed between the patient and their therapist.  That being said, outpatient psychotherapy is often extremely difficult and long-term, oftentimes requiring a number of years.

Medication treatments are often prescribed based on specific symptoms displayed by a particular patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or unstable mood, whereas antipsychotic medications may be used when there are distortions in thinking.  Brief hospitalization may sometimes be necessary during acutely stressful episodes, or if suicide or other self-injurious behavior becomes imminent.  Hospitalization can provide a temporary respite from external stressors.

Outpatient psychotherapy and medication management should be undertaken by a highly skilled and knowledgeable psychiatrist.  There are several in our local community with the experience and expertise necessary to effectively treat patients with Borderline Personality Disorder.  Santa Barbara Cottage Hospital Outpatient Mental Health Clinics utilize Dialectical Behavioral Therapy groups in order to improve their patient’s ability to tolerate distress and regulate emotions.  You can contact them at (805) 687-6681 to obtain information or schedule an assessment.