Borderline Personality Disorder

Published on 03/03/2015 by admin

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23 Borderline Personality Disorder

Kenneth Lakritz

Clinical Vignette

A 23-year-old woman was hospitalized after her parents brought her to the emergency department (ED) for treatment of an overdose of acetaminophen. Because of her history of drug abuse, her parents had refused to underwrite a spring-break vacation and the patient took the overdose to “punish” her parents The ingestion was minor and the patient was initially calm and friendly, but when ED staff expressed uncertainty about sending her home, the patient flew into a rage, accused staff of conspiring with her parents, and tried to bite a nurse.

This was her fifth psychiatric hospitalization in 3 years; all but one had been preceded by a suicide gesture or attempt. She lived with her parents and sporadically took adult education courses with a vague ambition to direct films. Despite high intelligence, she had failed three tries at college; in one instance, she had been dismissed for selling drugs. Although she had seen four respected therapists, she derided them as “only being in it for the money.”

Her arms showed multiple burn marks, and she admitted to burning herself with cigarettes “to relieve tension.” Her dentition was poor, and she acknowledged binge eating and purging.

Once admitted, she quickly established an alliance with a psychotic male patient and announced plans to move in with him when she was discharged. She was angry and sarcastic with some staff members but pleasant with others, leading to disagreements over her treatment and disposition.

Psychoanalysts of the 1920s and 1930s described patients who appeared superficially healthy but could not be psychoanalyzed because of their inability to establish a stable therapeutic relationship. These patients tended to have tumultuous life histories, poor social and vocational adjustment, and occasional brief regressions to psychosis. They were called “ambulatory schizophrenics,” “pseudoneurotic schizophrenics,” or “borderline schizophrenics.” The term borderline personality disorder is now the accepted terminology.

Clinical Presentation

In the 1950s, one subtype of borderline patient was isolated. These individuals had a persistent odd or flat affect, mild but stable thought disorder, and a family history of schizophrenia. Such patients suffer from a forme fruste of schizophrenia, and are now diagnosed with schizotypal personality disorder. The remaining borderline patients, those with DSM borderline personality disorder, are described as “the stably unstable.” They have rapid and overwhelming mood fluctuations, are often strikingly angry, and react disastrously to minor slights and disappointments (Fig. 23-1). Their interpersonal relations are intense and stormy. They fail to establish consistent vocational identities, frequently abuse drugs, injure themselves, and are liable to brief psychotic episodes when stressed.

Figure 23-1 Borderline Personality Disorder.

Developmental psychologists and psychoanalysts speculate that this syndrome originates with a disordered parent–child relationship in the second and third year of life. Either because of parental inconsistency or the child’s innate mood lability and aggression, the borderline child is unable to integrate disparate experiences of parental love and hostility into a stable, “internalized” parent, leaving the child oscillating between extremes of idealization with devaluation in self-image and perception of others. This scheme receives support from the well-documented high rates of childhood neglect and sexual abuse found in hospitalized borderline patients.

These patients rely on two primitive psychological defense mechanisms: splitting and projective identification. Splitting is the tendency to see self and others as either all good or all bad, often with rapid fluctuation between the two. Within a confined environment as found in schools and hospitals, splitting often occurs among staff and authority figures; some are idealized, whereas others are hated and feared. This often leads to conflict between the two treatment groups per se, causing the patient’s therapists to enact the patient’s conflict among themselves.

Projective identification is the unconscious process of assuming that another person has an undesirable trait or attitude and then acting in such a way as to evoke those traits. Therapists of borderline patients may find themselves overwhelmed with rage or contempt for their patient and will be tempted to act on these feelings.

Therapy

Borderline patients are exhausting to treat, because of their frequent crises, their simultaneous neediness and hostility, and their difficulty in establishing stable relationships. Dialectical Behavioral Therapy is demonstrating great promise. This is a comprehensive system of treatment with extensive institutional support for patients. Here therapists provide a persistent emphasis on diminishing unacceptable behavior as well as suicidal thinking.

No clear medication guidelines are available and none are likely to emerge, given the probable biological heterogeneity of this disorder. On the whole, though, second-generation antipsychotic medications have the most research support. Low-dose lithium and other mood stabilizers sometimes help. In contrast, benzodiazepines may not only disinhibit borderline patients but are apt to be abused. Whatever treatment is proposed, it is important to first rule out active substance abuse and bipolar disorder, two conditions with specific treatments that may mimic borderline personality disorder.

Additional Resources

Abraham PF, Calabrese JR. Evidence-based pharmacologic treatment of borderline personality disorder: A shift from SSRIs to anticonvulsants and atypical antipsychotics? J Affect Disord. 2008 Feb 25.

Gunderson JG, Hoffman PD, editors. Understanding and Treating Borderline Personality Disorder: A Guide for Professional and Families. Washington, D.C: American Psychiatric Association Press, 2005.

Linehan M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford; 1993.

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