The Essential Family Guide to Borderline Personality Disorder Page 4

  Treatment Challenges

  • No FDA-approved medication exists for BPD (although many medications are used to treat the symptoms).

  • BPD can co-occur with other illnesses. Most people with BPD also have depression.

  • An overwhelming number of clinicians do not have the training or experience to effectively treat those with the disorder. Research-based therapies for BPD are not widely available and are only appropriate for a subsection of those with the disorder. Eighty percent of psychiatric nurses believe that people with BPD receive inadequate care.6

  • A thirty-year-old woman with BPD typically has the medical profile of a woman in her sixties.

  Economic Impact

  • Up to 40 percent of high users of mental health services have BPD.

  • More than 50 percent of individuals with BPD are severely impaired in employability, with a resulting burden on Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Medicaid and Medicare.

  • Twelve percent of men and 28 percent of women in prison have BPD.

  Chapter 2

  Understanding Borderline

  Personality Disorder

  Do I contradict myself?

  Very well then I contradict myself,

  (I am large, I contain multitudes.)

  • Walt Whitman, “Song of Myself” •

  We’re going to cover a lot of ground in this chapter. First, we’ll look at the nine traits that make up the formal definition of BPD. Then, we’ll rearrange these traits to give you a better idea of how and why people with BPD act the way they do. Next comes:

  • Other common characteristics of people with BPD

  • The three subtypes of BPD

  • BPD in children and adolescents, men, and older adults

  • Other mental health problems that often go along with BPD

  But first, following are answers to a few commonly asked questions:

  1. Does “borderline” mean that people with BPD are on the border of something?

  The short answer is “no.” The long answer: A century ago, psychiatrists observed that some patients who generally functioned well got much worse when they talked while lying down on the couch. At the time, psychiatrists believed that all patients were either neurotic (think Woody Allen) or psychotic (a man who thinks he’s Jesus). Borderline personality disorder, they theorized, existed right in the middle, or on the “border.”

  Today, the mental health profession categorizes mental illnesses differently than it did a century ago, and there is no “middle” or “border.” But like many names that no longer hearken back to their original meaning, the name “borderline” remains. It may change one day, but don’t expect any action for many years to come.

  2. What is a “personality disorder”?

  A personality disorder is a pattern of inner experience and behavior that differs markedly from the expectations of the individual’s culture. It involves the way an individual responds to people and leads to significant distress. The traits must

  • be extreme, significantly affecting a person’s life

  • be enduring, a long-term pattern (years) of looking at the world and relating to other people

  • show themselves in a wide range of contexts1/

  3. Is BPD considered an “official” illness?

  Yes. The American Psychiatric Association added borderline personality disorder to its diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), in 1980, after obtaining input from experienced clinicians and professional organizations. The DSM provides descriptions of thinking, feeling, or behaving that fit the various diagnostic categories. Psychiatrists and other mental health professionals then use these DSM categories to diagnose mental disorders.

  The Nine Traits for Borderline Disorder

  Following is a very simplified interpretation of the nine criteria the DSM-IV-TR uses to describe borderline personality disorder. According to the DSM-IV-TR, an individual only needs to meet five of the nine criteria to qualify for a borderline diagnosis.

  1. strong reactions to fear of abandonment, whether real or imagined

  2. a history of troubled relationships with extremes in behavior and attitude

  3. poor sense of self

  4. impulsive and self-destructive behavior by at least two means (for example, substance abuse, self-mutilation, eating disorder)

  5. repeated suicidal tendencies

  6. intense and frequent moodiness and irritability

  7. an ongoing feeling of emptiness

  8. intense and uncontrollable anger

  9. persistent feelings of detachment

  Criterion 1: Fear of Abandonment

  Everyone fears abandonment to some extent. But the borderline brand of fear is more pronounced. Also, while most people generally respond only to real threats, people with BPD react to real or imagined threats. And they have a good imagination.

  Just as those with hypochondria consider a slight cough a harbinger of the black plague, people with BPD are hypersensitive to anything that smacks of abandonment. Once triggered, the over-the-top expression of fear cannot be easily assuaged. That’s because it originates from within, not from without.

  Susan Anderson, author of The Journey from Abandonment to Healing, says:

  Abandonment is about loss of love itself, that crucial loss of connectedness. . . . Sometimes it is lingering grief caused by old losses. Sometimes it is fear. Sometimes it can be an invisible barrier holding us back from forming relationships and reaching our true potential.2

  Abandonment doesn’t have to be physical, like walking out the door or slamming down the phone. It can be emotional distance or too much space in your “togetherness,” as author Kahlil Gibran would say.

  Most of us are healthy enough to handle it when important people in our life don’t agree with us about important things, or when they do things differently than we would. With people who have BPD, however, differences of opinions—even about something small—have an impact not unlike how it must feel when devout parents learn their child has decided to switch faiths. Not only is it a sort of abandonment; it can also be interpreted as a put-down of one’s most cherished beliefs.

  Recovered BP A. J. Mahari explains:

  Emotional distance can be caused by nearly anything. To be truly intimate without it being threatened, one has to be able to tolerate the distance (as well as the closeness). People with BPD are different in that they experience this distance as rejection. That causes them to desperately defend themselves against the very one they love and want to be close to. This distances the borderline’s partner and leaves the borderline feeling abandoned once again.3

  A woman with BPD reflects:

  During an argument, my boyfriend was trying to get away in his car. I stood behind him, trying to prevent him from leaving. When he maneuvered out of the way, I banged my fists on the back of the car. I ran to the door and tried to force it open, as he reached over and locked it. After he started down the street, I ran as fast as I could to catch up with him, begging him to stop.

  Criterion 2: Unstable Relationships Characterized by Alternating between Extremes of Idealization and Devaluation

  Because unstable relationships are at the core of this book, let’s take a look at the crucial second half of this trait: the BP’s pattern of idealizing and devaluing people. This thought process, called splitting, is insidious, affecting the way BPs see the world, themselves, and their closest relationships. As such, it lurks behind most of the troubles in a relationship.

  Most people can integrate their positive and negative feelings about a person and come to a place in the middle. BPs, however, cannot reconcile the two. They elevate others to an impossible standard and then knock them down when they inevitably disappoint. They see others as either their champions or as out to get them—and then can switch their opinion in a moment, not recalling that they ever felt differently.

  Rachel Rei
land, who wrote about her recovery from BPD in Get Me Out of Here, split her psychiatrist, Dr. Padget. When he empathized with her, she fantasized about actually being his daughter. When he seemed too distant from her, that sense of belonging was destroyed. Once she threatened to punish him by making false allegations about sex. When Dr. Padget switched back, all was forgiven—until the next time.

  A man with BPD says:

  When you are deep in the disorder, splitting is a complete and fundamental reality shift—you can remember that you felt the opposite way, but you can’t for the life of you understand why. It’s like someone who gets drunk, does something stupid, and wakes up the next morning saying, “What on earth was I thinking?”

  Criteria 3 and 7: Unstable Self-Image and Feelings of Emptiness

  In adolescence, we are still uncertain about our core values and beliefs. As we mature, most of us develop a sense of a stable, authentic self. But BPs never do. Playing a role—such as husband or mother—fills some of the emptiness. But when these roles are threatened—for example, a child becomes more independent, a spouse threatens divorce—the shell starts to crumble. This is why some BPs take extreme measures to keep the status quo: for example, accusing a partner of child abuse to prevent losing custody.

  People with BPD do have one core belief about themselves: They are unworthy. A borderline woman says, “My life is a nonstop struggle to be ‘good enough.’ I always think no one wants me around, no one cares about me, and my only hope of having people like me is to be perfect. When someone likes me, I wonder what they see in me that I don’t see in myself. When they go do things with their other friends, it hurts like hell, and I have to pretend that I don’t care. And that happens all the time.”

  Criterion 4: Impulsivity

  In an interview, Robert O. Friedel, MD, author of Borderline Personality Disorder Demystified, explains,

  People with BPD feel intensely in response to little things. Then boom, their emotions take over and the part of the brain that controls impulse is unable to moderate the intensity of their emotions. Anxiety and depression feed into the impulsivity. People with a reasonable amount of anxiety and good impulse control can say, “I’m going to make it; I’m going to be okay.” But the person with BPD doesn’t have that restraint.4

  Impulsivity is also associated with the rest of the DSM traits for BPD. When BPs are distressed, they can’t sit with it or think through the problem—especially adolescents. Instead, it becomes an immediate crisis calling for a dramatic 911 response, like taking mind-altering drugs or running away from home to meet someone you met on the Internet.

  Criterion 5: Self-Harm and Suicidality

  Michelle, a teenager, hates the way she looks. She hits her leg until it turns blue. Maggie pours boiling water on her arms to distract herself from her agony. Rod scratches his head until it bleeds and forms a scab.

  Self-harm can occur on a spectrum, from simple picking at the skin to making razor cuts so deep they require stitches. Other forms of self-injury are burning, branding, picking at scars, and piercing. Self-mutilation becomes a compulsion because it works. Tension builds up and is relieved by giving in to the urge.

  Self-injury is not an attempt to die. People engage in it to distract themselves from emotional pain, punish themselves, bring on numbness, relieve stress, maintain control, express anger, and communicate their pain to others. Cutting also seems to release endorphins, chemicals in the brain that promote a sense of well-being.

  According to Blaise Aguirre, MD, medical director of the Adolescent Dialectical Behavioral Therapy Center at McLean Hospital, Belmont, Massachusetts, adolescents who cut generally tend to describe themselves as being more sensitive than other kids their age, feeling things quicker than other people, and taking longer to get back down to their normal state than others. They may make excuses when their parents see injuries (“the dog bit me”). These signs, he says, may indicate self-harm activity:

  • consistently wearing long-sleeve shirts

  • spending too much time in the shower

  • isolating themselves after a fight or other stressful event

  • increasing substance abuse

  • hoarding sharp implements such as razor blades, tacks, and knives, as well as antiseptic solutions, bandages, and other first-aid paraphernalia5

  Suicide is another matter. For some, the concept of death serves as an escape fantasy. Like most people who make suicide attempts, they don’t really want to die. They’re just desperate to end their pain.

  A woman with BP says:

  My incredible sense of hopelessness made me feel like annihilating myself. I would continually up the ante. If I wasn’t satisfied with how people reacted to me because I overdosed on 200 pills, then the next time I would try 400 pills. I had an overwhelming and irrational need to somehow punish myself, destroy myself. It was my one purpose in life. The sense of emptiness and loneliness was very hard to tolerate.6

  Criterion 6: Affective Instability (Unstable Emotions)

  Affective instability has three components:

  • Intense feelings that are out of proportion to the triggering event.

  • These intense emotions go up and down much more quickly than those of a nondisordered person.

  • Once these intense emotions are triggered, it takes the BP a long time to return to a normal emotional level.

  A woman with BPD reflects:

  I’ll get irritated if I have to stop by the grocery store on the way home because it’s always crowded. I get home, and my daughter asks me if I’m in a bad mood. That irritates me more, so I snap at her. She snaps back. I seethe for the next sixty minutes until my TV program comes on. Five minutes later I am in a good mood, and I can’t understand why she’s so crabby. Doesn’t she know the argument’s over?

  Criterion 8: Intense Rage

  A BP rage is much more terrifying, shocking, and inexplicable than a normal rage. There is a change in the air, something palpable, before it erupts. Following is how one non-BP eloquently explains his partner’s rages.

  When in a rage, it seemed like she was channeling an evil spirit. Her eyes had no life in them: just a blankness. She didn’t see who I was or how she was hurting me. There was no way to negotiate, no way to reason or argue. She did not understand rational arguments.

  Her voice would become more rapid, accusatory, demeaning, patronizing, irrational, and paranoid. Her tone was very fast—rat-a-tat-tat—like she was offensively firing at me. She would pace and become very menacing, growing closer and closer as I became more and more afraid.

  She was no longer someone I knew, though I tried with all my power to talk her out of the fog. But it never worked. The rage seemed to need to run its course until she felt relief, no matter how much it killed me.

  A contributing factor of the intensity of the BP’s anger is that words aren’t enough to make others understand the depth of her emotions. Here’s an analogy: Imagine visiting a country where you don’t speak the language. Suddenly your chest hurts, and you’re having trouble breathing. You spot a police officer and urgently cry out, “I’m having a heart attack! I need an ambulance now!”

  Her response is a quizzical look and “Quijibo oompa loompa snoo-snoo?” You’d panic. Frustrated and frantic, you’d raise your voice and gesture more emphatically. “I could be dying!”

  In essence, sometimes BPs and non-BPs speak in different languages. The BP’s frenzied wrath becomes a way to try to get across her immediate needs—kind of a cry for help. Another explanation: dependency breeds anger. People with BPD feel that others have the power to define who they are. What’s even harder for them is that other people can give or withdraw love at any moment. That’s why small actions of others can make them feel good or out of control.

  Criterion 9: Dissociation

  People who dissociate feel detached, as if they were observing their body from the outside. Familiar objects look strange. Have you ever found yourself unaware that you were reading the sa
me paragraph over and over, or while you were driving, suddenly realizing that you missed the right turn a mile back? That’s dissociation. Focusing on the physical world (such as “my glass of iced tea is right here, in a blue glass with three ice cubes”) helps people stop dissociating.

  Alice, a BP, explains:

  Much of a borderline’s time is spent in oblivion, when the mind is so chaotic that the real world is very far away. There are periods of time I can’t remember at all, and I spend so much time in a blanked-out state. Even at work, I just go through the motions. I’m not really there.

  An Integrated Approach to Explaining BPD

  The DSM definition was developed to assist clinicians in making a clinical diagnosis. To better grasp the disorder and see it in action, we need a more integrated approach. We can do this by reorganizing the traits into three groups: traits that control thinking, traits that control feeling, and traits that control acting. These normally happen in sequence, one following the other like falling dominoes (although our emotions impact our perceptions).

  Let’s say you see a friend walking across the street. You yell “hi” and wave, but he ignores you. You feel hurt and a bit miffed, so you don’t invite him to your annual Fourth of July picnic. Later, you discover he’s hard of hearing. You thought he ignored you, you felt angry and miffed, and your action was to not invite him to your party.

  Impaired Thinking

  Splitting, of course, is the key cognitive flaw. Other cognitive distortions come in second. What myopia (nearsightedness) is to eyesight, cognitive distortions are to thinking. They shape our reality and dictate how we respond to people and situations. They are automatic, habit-forming, and invisible. It’s important to note that we all grapple with cognitive distortions. But as the chart on page 34 shows, in BPs, they can be much more extreme (be sure to note the distortion “feelings equal facts” because it will appear later in the book).

  Impaired Feelings

  The DSM traits having to do with feelings—emotions—are intense anger; unstable, irritable moods; fear of abandonment; and an overwhelming, constant sense of emptiness.