Borderline Personality Disorder

Transcription

1 Borderline Personality Disorder Etiology, Clinical Presentation & Treatment By: Rashin D Angelo Pacifica Graduate Institute 3/30/09

2 The borderline state refers to the quality of people who live on the border between neurotic and psychotic disturbance. Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self- image that begins in early adulthood and is present in a variety of contexts (American Psychiatric Association, 2000). The core features of affect instability, impulsivity, intense and inappropriate anger, and suicidal and self- mutilating behavior make these the most challenging clients even for experienced clinicians. BPD is often co- morbid with narcissistic, histrionic, and antisocial personality disorders (Trull, 2006). There is also a high rate of co- occurring Axis I diagnoses, particularly for Major Depressive Disorder, Substance Use Disorders, Posttraumatic Stress Disorder (PTSD), Panic Disorder and Eating Disorder (Harned, 2008). Given these findings, treatments for BPD must not only address the behaviors considered central to the disorder, such as suicide attempts and self- injury, but must also manage the difficulties associated with multiple Axis I disorders. Individuals with BPD have a profound fear of abandonment, manifested in desperate efforts to avoid being left alone, and a fear of enmeshment, presented in the tumultuous quality of intimate relationships. Frequent arguments and repeated breakups are some examples of maladaptive strategies that are highly characteristic of a close relationship. There is a pattern of unstable and intense relationships. They shift from idealization of a potential partner, to devaluing another whose rejection or abandonment is expected. There may be an identity disturbance characterized by unstable self- image, depicted by shifting goals, values, and career. Borderline patients often display impulsivity in at least two areas that are potentially self- damaging. These include gambling, reckless driving, unsafe sex, spending money irresponsibly, binge eating and substance abuse. There is recurrent suicidal behavior or threats, or self- mutilating behavior such as cutting or burning (American Psychiatric Association, 2000). These individuals have a range of intense 2

3 dysphoric affects, sometimes experienced as aversive tension, including rage, sorrow, shame, panic, terror, and chronic feelings of emptiness and loneliness (Zanarini, 1998). There is also tremendous mood reactivity, and patients often move from one to another with great rapidity and fluidity during the course of one day. They often express inappropriate, intense anger or have difficulty controlling their anger, which is often elicited when the feeling of abandonment arises. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (American Psychiatric Association, 2000). BPD does appear to cluster in families with high rates of impulsivity, including alcohol and substance- related disorders, antisocial behavior, and depressive mood disorder (Paris, 1999). There is consistent evidence of the role of psychological factors, particularly childhood trauma (e.g., physical and sexual abuse, parental loss), disturbed family setting or invalidating environments, and abnormal bonding in the development of this disorder (Adams, 2001). Etiology The cause of BPD is complex with several factors. Genetic factors and traumatic childhood experiences, such as abuse and loss, interact to cause emotional dysregulation and impulsivity, leading to dysfunctional behaviors and psychosocial conflicts and deficits, which again might reinforce emotional dysregulation and impulsivity (Skodol, 2002). The neurobiological factors of BPD are poorly understood. However, results of structural imaging studies indicate reduced hippocampal and amygdala volumes in these patients (Tebartz van Elst, 2003), both contributing structures to emotional regulation. What is not known, however, is whether the neurobiological dysfunctions are pre- existing i.e., due to genetic, pre- postnatal factors, or adverse events during childhood or the consequence of the disorder itself. Regardless of the etiology of the disorder, most theorists agree that this particular personality structure was created as a coping mechanism to splitting caused by early trauma. Kernberg considers splitting of inner representations of 3

4 self and others to be the central underlying pathology of the disorder. Splitting is an attempt to defend against the seeming impossibility of tolerating strong feelings or of mourning the co- existence of good and bad aspects. Splitting operations lead to an alternating expression of contradictory behaviors and attitudes often seen in borderline patients, and a compartmentalization of all persons in one s environment into all good and all bad camps (Kernberg, 1967). A large body of studies document disrupted early attachments and abuse in the histories of patients diagnosed with borderline personality disorder (Lyons- Ruth, 1999) and thus there is a high correlation of Post- traumatic stress disorder (PTSD) and borderline diagnoses (Herman, 1989). Childhood sexual abuse appears to be an important etiological factor in around 60% of reported cases and about 25% of borderline patients have a history of parent- child incest (Gabbard, 2000). Both diagnoses share massive disturbances in affect regulation, impulse control, interpersonal difficulties, self- integration, and a bias to use dissociation when under stress. Borderline personality structure is organized around the lack of capacity to hold an intermediary space between physical and psychic borders. There tends to be an oscillation between invasion anxiety during closeness to another, sensed as an internal disarray and severe feeling of sinking without clarity, and abandonment anxiety, experienced as paralysis and immediate disconnection from another which feels primitive and eternal. Nancy McWilliams discusses this dyadic struggle between total enmeshment, which they fear would obliterate their identity, and total isolation, which they equate with traumatic abandonment (1994, p. 52). Lacking this space between psyche and soma, borderline patients often give in to impulsivity, sadistic and masochistic tendencies and knee jerk reactions. The central issue in borderline personality disorder is the separation- individuation dilemma. When they feel close to another person they panic because of fears of engulfment and total control; when they feel separate, they feel traumatically abandoned (Masterson, 1976). Masterson sees borderline patients 4

5 fixated at the rapprochement sub- phase of the separation- individuation process, in which the child has attained a degree of autonomy, but still needs reassurance that the parent remains available and powerful, typically around the age of 2. He believes their mothers were deeply attached and responsive in early infancy, but discouraged the individuation that normally occurs between 18 months and 3 years. These individuals grow up feeling safe in regressed, dependent relationships, and suffer in aloneness. Closeness is thus comforting, yet with it comes a sense of being engulfed, controlled and infantilized. Separateness, despite being abjectly painful, is eventually empowering (McWilliams, 1994). In a borderline state, there also exists an impaired sense of time, for the patient cannot differentiate between past, present, and future. The past is held as the container of time, creating an eternal sense of imprisonment and an inability to be in the present. To be a borderline implies that a border protects one s self from crossing over or from being crossed over, and thus becoming a moving border. This in turn implies a loss of distinction between space and time (Green, 1986, p. 19). Lacking the capacity to represent absence, they often withdraw into inertia, flatness and psychic deadness, isolation where nothing exists except the negativity of the past. Primarily for this reason, effective treatment must be based on the here and now. Of importance is the therapist s own authentic presence in the relationship. Just as boundaries and the therapeutic frame become significant in treating this patient, so do compassion and genuine caring. Most patients who suffer from borderline personality structure experience numerous failures interpersonally. They lack the transitional space needed to tolerate loss and therefore withdraw interpersonally and idealize suffering. During early development, these patients probably did not have the appropriate mother- infant dyad, what Bion refers to as the container- contained relationship, to develop the internal depth necessary to interpret emotional experience. Bion proposes the infant projects into the mother the emotional experience that he is unable to process on his own (Ogden, 2004, p. 1357). A mother who is unable to be emotionally available to the infant returns his intolerable thoughts in a form that is 5

6 stripped of whatever meaning they previously held (Ogden, 2004, p. 1357). The infant s experience of his mother s inability to contain his projected feeling state is internalized as an incapacity to synthesize the positive and negative introjections and identifications (Green, 1986). Winnicott emphasizes the facilitating environment, primary maternal concern and holding in working with borderline patients. The concept of holding is seen as an ontological concept that is primarily concerned with being and its relationship to time (Ogden, 2004, p. 1349). The mother protects the infant s continuity of being by insulating him from the not- me aspect of time (Ogden, 2004). The mother feels herself into the infant s place (Winnicott, 1965, p. 304). This temporary merging requires a healthy mother with the capacity to separate once the infant releases her. A mother s providing live, human holding (Winnicott, 1965) is a selfless act, which allows the infant to take risk in coming together as a self. If her psychological pathology prevents her from providing this maternal holding, the infant s sense of being is disrupted. Kernberg stresses the importance of splitting between good and bad internal objects and self- images in borderline pathology (Green, 1986). This may be viewed as the child s reaction to the mother s attitude. A lack of the fusion on the part of the mother can create an experience of a blank breast for the infant; an excess of fusion can establish a sense of intrusion (Green, 1986). In borderline patients, the splitting also occurs between the two parents along the notions of the persecutory; and the idealized (Green, 1986, p. 39). Clinical Presentation Borderline patients are always suffering, for they lack the capacity for the intermediary, and complex grey areas of life. Andre Green (1986, p. 31) describes the unique characteristics as a lack of cohesiveness, a lack of unity, and above all a lack of coherence and an impression of contradictory sets of relations. Their inner experience is of a constant, free floating diffused anxiety, for which they seek discharge. Their deficiency around symbolization creates a difficulty in verbalizing 6

7 their experiences. As a result, the disorder is often expressed through self- mutilating behaviors, chronic feelings of emptiness, identity disturbance, and impulsivity in areas that are potentially self- damaging including drug abuse, hyper- sexuality, and binge eating. Their primary defense mechanisms, splitting, projective identification, negation, intellectualization, and denial, offer means of self- regulation and an attempt at homeostasis. The key feature of BPD is a pervasive pattern since early childhood of instability of interpersonal relationships, self- image, affect, and impulsivity (American Psychiatric Association, 2000). These individuals are prone to dramatic, sudden shifts in their appraisal of others, including the therapist, are exquisitely sensitive to interpersonal stresses, and often express extreme anger (Gunderson, 2001). They often present with severe issues and confusion over self- identity and may experience this identity disturbance as a black hole of emptiness or as feelings of worthlessness and extreme self- loathing (Gunderson, 2001). Interpersonal relationships of individuals with BPD are, by nature, explosive, stormy, and unstable; intimate relationships are established rapidly and with intensity, often followed by a questioning of the other s commitment (Woo, 2008). They may alternate between feeling consumed to feeling abandoned by others, and long- standing difficulties with interpersonal relationships are common. A friend s leaving on vacation or a partner s arriving home late or not returning a call is interpreted based on an intense fear of abandonment and rejection, which in turn may result in self- injurious behaviors (Gunderson, 2001). Affect lability, characterized by intense and chronically fluctuating emotions, is one of the defining features of BPD (Gunderson, 2001). They experience extreme emotions as reactions to events and interpersonal difficulties and feel unable to control the intensity. Their anger, centered more on loneliness than guilt, may be expressed as bitterness, physical aggression, extreme sarcasm, accusations, and hostility (Woo, 2008). Unable to tolerate the intensity of the dysphoric affect, the individuals act out impulsively or in a self- destructive manner (Brown, 2002). Self- 7

8 cutting or burning and suicidal gestures can serve as a distracting purpose, and become, for some, an addictive pattern of affect regulation (Linehan, 1997). During stressful periods, usually in response to real or imaginary abandonment, borderline patients tend to experience transient episodes of dissociation. The DSM- IV- TR describes dissociation as a disruption in the usually integrated function of the consciousness, memory, identity, or perception of the environment, which may be gradual, transient, or chronic (2000, p. 822). The presence of dissociation has been identified as a key factor that differentiates BPD from the other personality disorders (Wildgoose, 2000). Self- mutilation is found to be the most powerful predictor of dissociation. The pattern of behavior seen in BPD has been identified across cultures, yet has a high prevalence in women. BPD is about five times more common among first- degree biological relatives of those with the disorder than the general population (American Psychiatric Association, 2000). Although symptoms such as identity confusion and impulsivity may be displayed amongst adolescents that misleadingly give the impression of this diagnosis, the clinical symptoms appear in early adulthood and remit by middle age. During their 30s and 40s, the majority of individuals with this disorder attain grater stability in their relationships and vocational functioning (American Psychiatric Association, 2000, p. 709). However, severe stressors, such as divorce and death of a loved one can result in increased symptomatology (First, 2004). Differential Diagnosis BPD often co- occurs with Mood Disorders, particularly major depressive disorder, and when criteria for both are met, both may be diagnosed (2000, p. 709). There is also a high rate of other co- occurring Axis I diagnoses, such as Substance Use Disorders, Posttraumatic Stress Disorder (PTSD), Panic Disorder and Eating Disorder (Harned, 2008). Therefore, the diagnosis of BPD should be based on evidence of early onset and long- standing course of behavior, and not based solely on clinical presentation. 8

9 Other personality disorders may be confused with BPD because of common features. Histrionic Personality Disorder can also be characterized by attention seeking, manipulative behavior and rapidly shifting emotions (2000, p. 709), but BPD is distinguished by self- destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness (2000, p. 709). Paranoid ideas or illusions may be present in both BPD and Schizotypal Personality Disorder, but they are more transient and interpersonally reactive in BPD (2000, p. 709). Paranoid Personality Disorder and Narcissistic Personality Disorder can both be characterized by angry outbursts, the lack of impulsivity, self- destructiveness and abandonment issues differentiate them from BPD. Both Dependent Personality Disorder and BPD are characterized by a fear of abandonment; however, the person with Dependent Personality Disorder reacts by submissiveness and seeking an immediate replacement relationship rather than the rage and demands of a borderline patient (American Psychiatric Association, 2000). BPD must also be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system (2000, p. 710). It must also be differentiated from symptoms due to chronic substance abuse and identity concerns related to a developmental phase such as adolescence. The category of Identity Problem can be used when the focus of clinical attention is uncertainty about multiple issues relating to identity such as long- term goals, career choice, friendship patterns, sexual orientation and behavior, moral values, and group loyalties and not diagnosed as a mental disorder (American Psychiatric Association, 2000). Treatment Patients diagnosed with BPD usually seek treatment for symptoms of Axis I disorders. Effective treatment, therefore, integrates the full range of evidence- based approaches, as well as a psychodynamic approach focusing on the patient s inner world. In most cases, pharmacotherapy could be used to target certain symptoms 9

10 such as rapid mood shifts, and impulsive- behavioral dyscontrol, consisting of suicidal and parasuicidal behaviors and binge eating (Soloff, 2000) Due to the impulsive and self- destructive mannerisms of patients diagnosed with BPD, psychosocial interventions are often common with this population. Currently, there are two structured psychotherapeutic programs proven to be effective interventions for this disorder: Dialectical behavior therapy (DBT), a variation of cognitive behavioral therapy (CBT) developed by Marsha Linehan, and psychoanalytic approach focusing on object relations based on theories of Winnicott, Bion, Kernberg and others. Dialectical Behavior Therapy DBT is a behaviorally oriented outpatient psychotherapy designed specifically for patients diagnosed with BPD. Treatment goals are hierarchically ordered by importance as mainly reduction of suicidal, life threatening, and other behaviors that interfere with therapy and quality of life (Linehan, 1993). A manualized treatment that includes weekly individual and group therapy, DBT combines strategies from behavioral, cognitive, and supportive psychotherapies. Individual therapy applies direct, problem- oriented techniques, including behavioral skill training, contingency management, cognitive modification, and exposure to emotional cues, balanced with supportive techniques, such as reflection, empathy, and acceptance (Linehan, 1993). Behavioral goals are prioritized according to importance. The emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. DBT emphasizes the following four therapeutic areas: Acceptance and validation of behavior in the moment; treating therapy- interfering behaviors of both client and therapist; the therapeutic relationship as being essential to treatment; and the dialectical processes (Linehan, 1993). Linehan (1993) defines dialectics as an attempt to view the whole picture and issues on a micro level, as well as an internal set of opposing forces in the individual. The behavioral features 10

11 inherent in BPD, such as extreme emotional expression, are viewed as dialectical failures, and therapy must focus on restoring the balance. Linehan believes that abuse is neither necessary nor sufficient for the development of BPD. She uses the term invalidating environment as a more general description of childhood environmental variables, which interactively contributes to the development of the disorder (1993). The purpose of DBT is to give care back to the individual by validating the client s current emotional and behavioral responses. Linehan (1993) suggests the model is about reducing inner conflict while validating experiences and feelings in a collaborative way with the therapist. Object Relations Therapy Object relations theorists have emphasized understanding the patient s experience of relationship, attachment and separation. Using Erikson s developmental stages, patients could be conceptualized being fixated at either primary dependency issues (trust vs. mistrust), secondary separation- individuation issues (autonomy vs. shame and doubt), or more advanced levels of identification (initiative vs. guilt) (McWilliams, 1994, p. 51). Kernberg has described how borderline functioning characterizes individuals who are pathologically fixated at the level of ego development, in which object representations of the self and the other have been differentiated but before the good and bad aspects of each have been integrated (Kernberg, 1975). The toddler originally experiences the mother in alternating states of all good and all bad, because the early ego does not have the capacity to integrate these discrepant images (Mahler, 1975). This failure of integration creates a lack of cohesiveness and unity, and a coexistence of contradictory thoughts, affects and reality principle (Green, 1986, p. 37). This failure in integration gives the impression of an aloofness and absence of life, a blank psychosis (Green, 1986); an emptiness that characterizes the experience of a borderline patient. There is a failure to create what Winnicott referred to as transitional phenomena (1965), the potential space between the 11

12 inner and outer world, which is also the space between people that allows or intimacy and creativity. People in a borderline condition tend to be fixated in dyadic struggles, between total enmeshment, which they fear would obliterate their identity, and total isolation, which they equate with traumatic abandonment. This central conflict results in their going back and forth in relationships, including the one with the therapist. Lacking the transitory bridge, borderline patients need a narcissistic double to facilitate the holding environment necessary to synthesize their positive and negative aspects of themselves. The conscious analyst, aware of the significance of this role, can serve as the bridge, or the mother, to help them tolerate their independence. It is important to hold the balance between firm boundaries and flexible timing, so as not to re- traumatize the patient. If the analyst is able to modify the patient s undigested raw feelings, the infant s nameless dread not internalized by the mother, they develop into memories and meanings. Early trauma and splitting can therefore be interpreted into symbolic insights to help patients create a new story. Borderline patients can move forward by internalizing an imperfect, tolerant, and direct parental figure represented by the therapist. By learning to tolerate their own imperfections, they move towards grieving and mourning loss vs. enduring suffering. It is important for them to feel supported yet not placated, the appropriate balance between abandonment and enmeshment. The aim of therapy thus becomes the development of an integrated, dependable, complex, and positively valued sense of self (McWilliams, 1994, p. 63). Winnicott has emphasized the importance of the analyst s counter- transference, ranging from a strong desire to rescue to an unnecessary punitive attitude, as a core instrument in working with borderline patients. Counter- transference tends to be quite strong in working with borderline individuals. Feelings of ineffectiveness, hopelessness, hatred and anger are common amongst therapists working with this population. It is extremely significant to use 12

13 transference as material to connect with their unconscious. Winnicott discussed the importance of teaching a borderline the ability to navigate between deficiency of symbol formation and conflict around guilt (Winnicott, 1965). Ruthlessness is a way of distancing the therapist, so the self can emerge. Since they do not have the capacity to tolerate pain and distress, they use various means of evading pain. The therapist, therefore, must be able to modify their unprocessed raw feelings, which are often preverbal, so that memories and meanings can develop. Much still needs to be learned about borderline personality disorder. Perhaps early intervention and prevention strategies during adolescence could be developed. Psycho- education of the patients families is very important since it enables them to become allies in the treatment of this debilitating disorder. Finally a shift in attitude amongst the mental health professionals, from one of distaste and resistance of working with this population, to one of empathy and collaboration is necessary for better treatment prognosis. References: Adams, H. L. (2001). The classification of abnormal behavior: An overview. In H. E. Sutker, Comprehensive handbook of psychopathology (pp. 3-28). New York: Kluwer academic/plenum Press. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Vol. 4th edition TR). Arlington, VA: Author. 13

14 Brown, M. Z. (2002). Reasons for sicide attempts and nonsuicidal self- injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111, First, M. B. (2004). DSM-IV-TR mental disorders: Diagnosis, etiology and treatment. Hoboken, NJ: Wiley. Gabbard, G. (2000). Psychodynamic psychiatry in clinical practice (3rd ed. ed.). Washington and London: American Psychiatric Press. Green, A. (1986). The borderline concepts. London: Hogarth Press. Gunderson, J. G. (2001). Borderline personality disorder: A clinical guide. Washington, DC: American Psychiatric Press. Harned, M. S. (2008). Integrating dialectical behavior therapy and prolonged exposure to treat co- occurring borderline personality disorder and PTSD: Two case studies. Cognitive and Behavioral Practice, 15, Herman, J. P. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry (146), Kernberg, O. (1967). Borderline personality orgnaization. Journal fo the American Psychoanalytic Association, 15, Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson. Linehan, M. M. (1997). Behavioral treatments of suicidal behaviors: Definitional obfuscation and treatment outcomes. In D. M. Mann, Neurobiology of suicide: From bench to the clinic (pp ). New York: Annuals of the New York Academy of Sciences. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Lyons- Ruth, K. &. (1999). Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral and attentional strategies.. In Handbook of attachment: Theory, research, and clinical applications (pp ). New York: Guilford Press. Mahler, M. S. (1975). The psychological birth of the human infant. New York: Basic Books. Masterson, J. (1976). Psychotherapy of the borderline adult. New York: Brunner/Mazel. McWilliams, N. (1994). Psychoanalytic diagnosis; Understanding personality structure in the clinical process. New York & London: The Guilford Press. 14

15 Ogden, T. H. (2004). On holding and containing, being and dreaming. International Journal of Psychoanalysis, Paris, J. (1999). Borderline personality disorder. In P. B. T. Millon, Oxford textbook of psychopathology (pp ). New York: Oxford University Press. Skodol, A. G. (2002). Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive- compulsive personality disorder. American Journal of Psychiatry, 159, Soloff, P. (2000). Psychopharmacology of borderline personality disorder. Psychiatry Clinic North America, 23, Tebartz van Elst, L. H. (2003). Frontolimbic brain abnormalities in patients with borderline personality disorder: A volumetric mangetic resonance imaging study. Biological Psychiatry, 54, Trull, T. J. (2006). Borderline personality disorder. In J. C. M. Hersen, Comprehensive handbook of personality and psychopathology: Adult psychopathology (Vol. 2, pp ). Hoboken, NJ: Wiley. Wildgoose, A. W. (2000). Psychiatric symptomology in borderline and other personality disorders: Dissociation and fragmentation as mediators. Journal of Nervous and Mental Disorders, 188, Winnicott, D. (1965). Primary maternal preoccupation. In The maturational processes and the facilitating environment (pp ). New York: International University Press. Woo, S. M. (2008). Diagnosis and treatment of mental disorders across the lifespan. Hoboken, NK: John Wiley & Sons, Inc. Zanarini, M. C. (1998). Axis I comorbidity of borderline personality disorder. American Journal of Psychiatry, 155,