What is Borderline Personality Disorder (BPD)?

According to the Diagnostic and Statistical Manual IV, BPD is diagnosed when there is an instability in interpersonal relationships, self-image, mood swings and impulsive behaviour. A person with Borderline Personality Disorder (BP) often feels both dependent and hostile towards their supporters which makes for a very tumultuous interpersonal relationship. In general, people with BPD feel empty, moody, needy, depressed, fear being alone and fear being abandoned. They are looking for that person who can give them the love that they can’t give themselves, the person who can fill the hole left deep within them. BP’s see things as black or white, I love you or I hate you and base their shallow beliefs on feelings rather than facts. A BP’s beliefs are shallow as they don’t have a belief system of their own; they are usually following other people beliefs and thoughts. Dealing with this pain is done two ways ‘acting in’ or ‘acting out’. Acting in is when they self injure (SI), make suicide attempts, abuse alcohol and/or drugs, express self-hate and uselessness. Acting out is when they focus on their partner/family by laying blame on them for all their problems, make unfair and often fabricated accusations, emotionally abuse them, placing their partners/family in ‘no win’ situation and use emotional blackmail to get the love they need. Having said all of that remember the most important issue, BP’s are living in pain and fear – each and every day. Most of the time their actions are a result of them getting through each day, this is how they survive.

A person with this disorder will exhibit a majority (5 or more traits) of the following symptoms:

• frantic efforts to avoid real or imagined abandonment
• a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• markedly and persistently unstable self image or sense of self
• impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, alcohol, drugs, reckless driving, binge eating)
• recurrent suicidal behavior, gestures, or threats, or self mutilating behavior
• unstable emotional states which are easily triggered and last from anywhere between an hour and a few days
• chronic feelings of emptiness
• inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, abusive behaviour, recurrent physical fights)
• transient, stress related paranoid ideation or severe dissociative symptoms

The interesting point here is that every person on this earth experiences some or all of the above at some time in their life but it is the frequency and intensity that distinguishes BPD.

Statistics on this disorder

Firstly I must apologize as the only figures I can give you are based on American studies. After going to six Australian Mental Health sites I had trouble finding BPD being mentioned, let alone having statistics on the disorder. I was referred to a Psychiatrist to help me to deal with my girlfriends BPD and his opening comment was "of course you realize that our Association has yet to accept and recognize this disorder"!!

SANE Australia, who work in partnership with Mental Health Council of Australia, ACROD, Royal Australian and New Zealand College of Psychiatrists, Royal Australian College of General Practice, Federal and State Health Departments, state "about two in every hundred people with develop BPD at some time in their lives - that is more than 300,000 Australians. Women are three times more likely to be diagnosed with BPD than men". This is a very, very conservative figure considering the continuing non recognition of the disorder here in Australia, the lack of actual knowledge and training Clinicians have received on BPD and the stigma that is attached to it. Even 2% of our population is approximately double those who suffer from Alzheimer's disease and is nearly that of Bipolar and Schizophrenia combined. Since many of you have heard of Alzheimer's, Bipolar disorder and Schizophrenia and since so much Government funding has gone towards research into these disorders one has to ask - what is it about Borderline Personality Disorder that it can't even be officially recognized let alone funded for research? I have yet to meet anyone who asked for or deserved this disorder yet some who know about it openly decided to do nothing about it. People who suffer from this disorder and do so on a daily basis. A day filled with emotional pain, uncertainty, black and white thinking, mental stress and a will to survive these 24 hours as best they can - perceived or actual.

An interesting issue of BPD is that the 2% statistic that is mentioned does not include family/partners who finish up in some form of therapy and/or on medication. American studies show that 70% of the people who love/care for a BP require therapy or medication. Australia's population and as at 1 January, 2004 was 20,000,000 and this means conservatively some 400,000 Australians suffer from Borderline Personality Disorder and a further 200,000 family/partners (Using approx 50% of sufferers figure) finish up requiring therapeutic or medicinal assistance.

BPD makes up 20% of the inpatients in the American Mental Health system and it is their fastest growing Mental Health population. BPD makes up 11% of out patients in their system. Along with these staggering figures is the fact the 70% of loved ones and family who were the support group of the BP finish up seeking some sought of assistance through therapy. At the moment a very conservative 2% of America’s population is deemed to be suffering from BPD. This figure is conservative because of the stigma attached to it, insurance denials on the disorder and a lack of understanding and training amongst clinicians. The figures I have seen listed as 'Australian' relate very closely to these percentages presented here.

Causes of this disorder

I do not have enough information or qualifications to be talking about this and I direct you to the information supplied by the experts on their web site (Refer Links). What I do understand is that many, not all, report a history of sexual abuse, neglect and/or separation as a child. Up to 71% of BPD patients in America reported having been sexually abused as a child by a care giver, usually a friend of the family. Along with this was a fair % who were sexually abused by family members or had their privacy constantly invaded by them. The damage this treatment does to a child is definitely an area that needs to be addressed as the 'child within' remains scared and this must be dealt with before attempts to recover from this disorder can be started.

Childhood is the most precious common right of all children.

~mjtacc~

BP’s Are Not to Blame, the Disorder Is

Many people still carry the misperception that personality disorders occur because the person is weak or they somehow deserved it! That is so, so wrong and I guarantee you that no one on this earth ever asked for or deserved this disorder. No one. The problem is that people suffer from it and others suffer from their suffering. Blaming the BP often happens when the disorder isn't known about because rationally they cannot work out why their daughter, husband, partner etc is acting the way they are. As many describe such an existence as a "roller coaster" ride of emotions. There reactions are generally not about the person but more associated with their irrational actions and emotional changes. Non's (family member, someone in a relationship, partner) do not understand at first that the BP's are not consciously holding themselves back, yet they clearly see their loved one can't seem to move forward in any steady manner. They see them doing so well in their work, they see them being so loving to others and they can't understand what is happening to their own household/relationship. Help is available and treatment can lead BP's back to leading a 'normal' lifestyle but the BP has to want to face this and any associated disorders and then deal with it. Blame sometimes is thrown when nothing is done and denial of the disorder continues but again from a BP perspective, that is the only way they know how to survive on a day to day basis and some think that their life is actually quite normal. The most important thing to remember is that the person themselves is not to blame, the disorder and possibly their past is. But if they become aware of the disorder and choose not to do anything about it then they have some real issues to deal with. No one can help a person to get better except the person themselves, all others can do is be there to support.

"You can't get away from yourself by moving from one place to another. There's nothing to that."

~Ernest Hemingway~

MYTHS OF BPD

The following information was compiled from an article written by Dr. Leland M. Heller, M.D.

The DSM (Diagnostic & Statistical Manual) contains the definition of psychiatric disorders. These criteria based definitions are the results of a consensus created from hundreds of psychiatrists of many different perspectives and beliefs from all over the world. As research becomes available, these definitions are revised. The latest publication of the DSM IV was in 1994.

Physicians have the right to explain and treat disorders according to their knowledge, training and expertise - but not to establish their own criteria for a particular illness. And in most cases, all of the criteria for an illness does not have to be apparent for a diagnosis. Therefore, a physician cannot say, for example--"I don't believe you have diabetes because you are not thirsty". All areas have to be considered carefully. Also if a physician disagrees with the established criteria, he/she needs to explain the reasoning in the chart.

Unfortunately, due to the nature of Borderline Personality Disorder, there are many misconceptions about the diagnosis:

1. that the diagnosis is based on why it may have happened -- NOT TRUE! There is no one clear cut biological or environmental factor that causes a person to develop BPD
2. that the diagnosis is based on severity of symptoms -- NOT TRUE! BPD is unique to each person. Some people with this illness are severely debilitated while others are high functioning. Some are habitually suicidal while others never reach that point.
3. that the diagnosis somehow requires a response or lack of response to certain medications be made -- NOT TRUE! Because of the many biological and environmental factors that effect a person's development, there is no one medication that can effectively treat all persons with BPD. Plus each person's chemical makeup reacts differently to medication in regards to dosage, side effects and effectiveness.
4. that the diagnosis is based on the actual brain or thought mechanisms involved -- NOT TRUE! No clinical proof has yet been given to verify actual brain functioning or thought patterns related specifically to BPD. Although it is currently believed that the serotonin levels in the brain may have something to do with this disorder.
5. that missing some symptoms--such as self-mutilation--means the diagnosis is not present -- NOT TRUE! A person does not have to meet all nine of the diagnostic criteria, nor do they have to show symptoms relating to specific criteria on the list. Any five of the nine criteria need to fit this definition for a diagnosis
6. that the diagnosis has a predictable outcome for everyone -- NOT TRUE! Like any illness, the outcome of a BPD is related to many factors including proper diagnosis and medical treatment, willingness of client to participate in treatment and therapy, and a qualified and knowledgeable physician.
7. that it's a label and not a diagnosis -- NOT TRUE! Persons with BPD have an illness, they are not the illness, much in the same way that a person with cancer is ill, they are not cancerous.
8. that having the BPD or Bipolar diagnosis means one cannot have the other diagnosis as well -- NOT TRUE! They are not mutually exclusive and many individuals have more than one diagnosis, including both BPD and Bipolar.

It's crucial to remember that it is a criteria based illness and is described as a "pervasive pattern... beginning by early adulthood and present in a variety of contexts..." For the BPD to be diagnosed, five of the nine criteria need to fit this definition.

Everyone learns specific skills whilst growing up--how to deal with other people and form relationships, how to feel emotions and control them appropriately for the situation at hand, how to cope in distressing situations, and how to develop the self (self awareness, self image, self identity).

For people with BPD, this skill building is "interrupted" either by a neurochemical reason (chemical imbalance), an environmental reason (neglect in home life), or a crisis situation (such as sexual and/or physical abuse). The person actually stops learning these skills, and instead of learning and maturing in skill development, holds onto specific immature ways of dealing with their situation. This lack of skill development often appears when a person reaches their late 20's early 30's as they have difficulties handling life's situations and relationships. In times of crisis, the person can appear very childish and confused. And as she/he gets older, the childish skills no longer work in the adult world. Frustration, loss of self, depression/anxiety takes over and their thoughts of those childhood years come flooding back.

~mjtacc's~ thoughts

Picture it this way: As we grow we learn skills to appropriately deal with life. It's like we have a tool bag of supplies to reach into when various situations arise. These are our basic coping skills. We gain a solid sense of self from the people around us who validate our feelings, our beliefs, our actions and our opinions. A strong sense of 'Who We Are' is a heavy duty tool to use as we grow towards adulthood and become that person we want to be. We learn emotional regulation--appropriate ways to show emotion when situations occur, controlled ways to experience anger, sadness, fear, grief, love, etc. Our emotions remain in check. We learn interpersonal regulation---how to deal with people, how to form relationships, how to get our needs met while maintaining self respect, how to keep and maintain healthy relationships with people in our life. We build friendships, find significant others and maintain important relationships with people and professionals that help and care for us. We learn distress tolerance---how to deal with stress and crisis situations in our life. We maintain control and work towards positive outcomes when a crisis situation arises. We appropriately deal with the situation without losing control of our emotions or losing a sense of self. We consciously work towards a positive solution. We are human and at times our emotions runs free and strong which is a great outlet and recognition of what has happened but this is an irregular outburst and is qualified by the gravity of the situation, death of someone close being a good example.

A person diagnosed with BPD has an empty tool bag. They did not learn these basic coping skills. Most often the reason being is that they grew up in an environment that did not validate who they were as a child and later as a person. Who they were didn't matter. Another possible reason this skill development was interrupted and/or not developed could possibly have been emotional, sexual, and/or physical abused. A person with BPD may have no true sense of who they are, their emotions are extreme and not always in control or regulated. They have a difficult time with relationships because they don't know or understand how to develop them appropriately, and in crisis situations they often go to extremes or "fall apart". (An interesting observation is that this emotional/relationship dysfunction generally doesn't take place in the workforce, just with those who get close to them). Childhood may have taught them that love equals hurt and to let someone love them is to open themselves up to further hurt. BP's sometimes tell their partner/family member to back off as they are doing their best with the tools they have but the problem is that their tool bag is empty. Stress is placed on the marriage/relationship/family unit because the BP wants to continue the way they currently are and the partner/family members know it cannot last without some form of change. Distress tolerance is not there, causing the BPD to become extremely depressed, self-injurious, and possibly suicidal. They will become very needy and clingy to specific persons that they have gained some trust, a trust that will be constantly questioned. They need to be loved, they let people get close to them then the fear of that person knowing who they really are takes over and things fall apart. Their fear of abandonment and their constant questioning of trust puts up a major barrier between themselves and their partner/family. They crave to be loved, wanted, needed but their childhood experiences may have taught them not to trust a person who provides this. The one who loves and supports them is slowly driven away by this seemingly empty tool bag.

Can the tool bag have a few things in there? YES, YES, YES. My background of Management Training has taught me these interpersonal and coping (Cognitive) skills can be learned. There is only one criterion – the BP has to WANT to learn them. And no, it is not as simple as that. The pain they endured during their childhood needs to be addressed and a sense of ‘moving on’ from those childhood scars needs to be achieved. The revisiting of the inner child is essential and the issues of their hurt 'inner child' needs to be addressed. Most importantly is that the hurt 'inner child' doesn't need any more pain yet the road they are currently travelling constantly hurts themselves and their 'inner child'. It's a re-mapping from childhood to adulthood where skills are learned and nurtured. Yes it is achievable and the starting point is deciding that they really want to do it. And it should be noted that a family member/partner can never force the BP to change, only the BP can help themselves. Next, find a qualified professional who is experienced with this disorder and they will walk you through the treatment options. Don't do this alone. Set up a support system for yourself, someone/s to talk to about your therapy, someone who fully supports the therapeutic process, someone who knows what goals you are striving for and can be there for you, someone who will understand what you are trying to achieve yet strong enough to call a spade a spade. Achieving is believing and there is no better place to start than them believing in themselves and the partner/family believing in them.

Personally I have a major problem when people with a disorder have had 5 years of therapy and they still have nothing in their tool bag. They still have so many issues, are in so much emotional pain and keep driving their family/partners away from them. The recovery is something between only the patient and their clinician - it's a closed shop. Everyone else in this person's life is to sit back and wait to pick up the pieces. The BP may stop taking their medication, they may stop going to therapy, start self injuring themselves again, they may be struggling with a goal or be having problems coping with change …………… but that's OK because their clinician will be there for them next week/fortnight/month and they'll talk about it yet again then.

What therapeutic goals were set for them to achieve? What treatment plan was established? Were family/partners involved in the re-mapping or at least educated about the recovery process? What goals were actually achieved over those 5 years? What support system outside of the therapy were established? And most importantly - after 5 long, hard years what skills do they now have in their tool bag?

Revised Feb 2004