Tuesday, December 23, 2008

BORDERLINE PERSONALITY DISORDER...notes from a concerned psychiatrist

In the space of five months Ada had changed department three times. She would start in each department with an amiable commitment, appearing humble, willing to learn and to contribute. She was quick to express appreciation to the H.O.D leaving you with the impression that she was a seasoned sycophant. Before you could say “thank God it’s Friday” she would suddenly become cold, accusing everyone and sometimes she would become frightenly angry and then after a few hours she would become pleasant again. Everyone literally walked on glass around her because her moods were so unpredictable. She would appear over possessive and “needy” and then almost immediately turn round to appear as if she didn’t care about the same person anymore.
Then stories of her past started trickling in…..” We heard she has had psychiatric treatment for depression”…… “She has also sliced her wrist on two or more occasions”…….. And when her story finally came up when we were all gathered together, we recounted our individual experiences and all agreed that even though we couldn’t place our fingers on it, Ada truly had some serious issues!

The lady above had some features suggestive of a depressive disorder but in actual fact, Ada had a mental health condition known as BORDERLINE PERSONALITY DISORDER.
Personality simply refers to the enduring qualities (traits) that make you a unique individual and determines your emotional and behavioural responses to various circumstances of life. Personality disorders are deeply ingrained maladaptive patterns of behaviours recognizable by the time of adolescence or earlier and continuing through most of adult life although it becomes less obvious in middle or old age. Now nobody is perfect so we all have some maladaptive behaviour, for example, a “hot” temper, a tendency to bear grudges etc. However, the difference between the regular personality and the disorder is that the individual suffers and other persons around them in the family, workplace, romantic relationships, friendships etc have to suffer too. Simply put, it has a negative effect on the individual and the society. There are various personality disorders such as the antisocial (extreme cases are called psychopaths), the avoidant, the dependent and so on but today, let’s look at Ada’s issue…

What is Borderline Personality Disorder?
Let me start by saying it is a controversial diagnosis because the diagnostic criteria is quite broad that it seems to encompass several abnormal aspects of personality. The key to recognizing BPD is instability: instability as it relates to their moods, interpersonal relationships and self-image. Their emotions are quickly and easily aroused and more intense than those of others. This pattern of behaviour would have persisted for years and is present in a variety of settings like home, work e.t.c.
Though it is difficult to reliably identify personality disorders in the community one study gave an estimated prevalence rate of BPD at 1.1 to 4.6% in the general population. It is significantly more common in women; three times more common than in men, and among people who are either widowed or unmarried.

What is the cause?
Though the cause is not certain Linehan, based on her success in managing people with this disorder, put forward a theory that borderlines are born with an innate biological tendency to react more intensely to lower levels of stress than others and they take longer to recover. They peak “higher” emotionally on less provocation and take longer coming down. In addition they are raised in environments which their beliefs about themselves and their environment were continually devalued and invalidated. These factors combine to create an adult who is uncertain of the truth of their feelings. Various studies have shown that there is a higher incidence of abuse, particularly sexual abuse, in the early life of individuals who suffer from this disorder. Sexual abuse is as high as 40-71% in BPD patients, usually by non-caregivers.

How to Recognize It
The following features indicate a borderline personality disorder; the presence of at least five out of these nine features is diagnostic.
1.A pattern of unstable and intense interpersonal relationships because they alternate between extremes of idealization and devaluation. People with this disorder tend to see people in either “black-OR-white” term (NO GREY AREAS!).They engage in extreme and confusing fluctuations between being over possessive and being totally disinterested (I hate you…don’t leave me) and in the scenario of a romantic relationship, this behaviour eventually makes their partner leave.
2.BPD patients exhibit intense mood swings ranging from extreme irritability to a high level of anxiety which lasts briefly; within hours and in rare cases, a few days.
3. Frantic efforts to avoid real or imagined abandonment from family, friends or even casual acquaintances so they tend to be manipulative
4. Chronic feeling of emptiness arising from a continuous feeling of loneliness even if they are constantly surrounded by people who care. They have heavy need for affection and reassurance. They usually feel they “need” someone to survive.
5.Recurrent suicidal behaviour, threats, or self mutilating actions. This should be taken very seriously! Every suicidal gesture or threat made should be a reason to invite a psychiatrist because the suicide rate in these individuals is 9 times more persons without BPD.
6. Displays of intense and inappropriate anger that is difficult to control that often embarrass the borderline later.
7.Impulsive behaviour in at least two areas that are potentially self destructive such as compulsive spending, compulsive sexual behaviour, alcohol and other drug abuse, reckless driving, gambling, shoplifting or eating disorders.
8.Transient stress-related paranoid ideation, i.e. when faced with pressure, they falsely accuse people, or severe dissociation: this “means out of it” or not being able to remember what they said or did especially during severe stress.
9.Uncertainty about personal identity; this uncertainty is shown in at least two areas which can include self image, sexual orientation, career choice or other long term goals, friendships and values. Borderlines have unstable self image and have been known to recurrently ask questions like who am I really? Why am I here?
Despite the marked instability some borderlines have unusually high degree of interpersonal sensitivity, insight and empathy. Some are also very smart, appear full of life and are funny.

BPD can be difficult to manage because these features are like deep seated habits however, with help, many improve over time and are eventually able to lead productive lives. The most successful psychotherapeutic approach called the Dialectical Behavioral Therapy developed by Marsha Linehan aims at teaching the individual to take control of their lives, emotions and themselves through improved self knowledge, building of self esteem, emotion regulation and restructuring of the individual’s mindset.
Dialectic refers to the therapist’s accepting and validating the patient as she is, on the one hand, while at the same time insisting on the need for change. The idea is to give the patient tools she never acquired as a child, typically to control and deal with her emotions. Some patients, when asked after many years of treatment, why they have stopped inflicting self-injury, answer “I picture myself sitting with my psychotherapist, and we talk on why I want to harm myself?”
During the early days of developing this form of therapy it took about a year of treatment to see substantial enduring improvement however combining antidepressants and mood stabilizing medications with the psychotherapy (probably the standard treatment now) seems to give satisfying synergy and faster results.
People with this personality disorder or their loved ones could go ahead and check these websites for more information:


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