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Borderline Personality Disorde Essay, Research Paper

BORDERLINE PERSONALITY DISORDER

Copyright 1999 John M Rathbun MD

DEFINITION – a pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsiveness, beginning by early adulthood and present in a variety of contexts

HISTORY:

* this diagnosis has been used over the past 30 years to label patients who get therapists upset.

* BPD has become the most diagnosed and researched personality disorder.

EPIDEMIOLOGY:

* two or three per cent of the general population are affected

* most common personality disorder in clinical settings

* diagnosed in 11% of psychiatric outpatients, 19% of inpatients, and about half of all personality disordered patients

* three times as common in women as in men

* five times more common in first degree relatives of affected persons

ETIOLOGY:

* well over half are victims of physical and/or sexual abuse

* dysfunctional family dynamics are common

* mothers often erratic and depressed

* fathers often absent or have major character problems

* early losses common

* genetic data implicate constitutional factors

DIAGNOSIS:

* typically present with dependent behaviors, seeking nurturance, closeness, and assistance

* within a therapeutic relationship, show escalating need for support

* when frustrated, show rage and devaluation of therapist

* relationships typically unstable, intense, and stormy

* they show extremes of idealization and devaluation

* may become extremely ill and self-destructive in reaction to fear of abandonment

* commonly have other personality disorders, mood disorders, substance dependence, bulimia, and PTSD

DIFFERENTIAL:

* Compared to cyclothymic and bipolar patients, BPD more reactive, angry in reaction to frustration in dependent relationships, with chronic feelings of emptiness

* compared to depressive disorders, BPD more manipulative in their suicidality and have poorer relationships

* compared to psychotic disorders, BPD have brief, reactive psychotic symptoms, not chronic, persistent ones

COURSE:

* typical BPD emerges in adolescence

* BPD especially severe in twenties

* about half improve spontaneously in thirties and forties

* BPD commonly fail in education, employment, and relationships

* suicide claims eight to ten per cent; many more carry scars of self-mutilation

MEDICAL TREATMENT:

* SSRIs and mood stabilizers help impulse control and moodiness

* antipsychotics help ideas of reference and brief psychotic symptoms (newer antipsychotics especially olanzapine)

* benzodiazepines and MAC’s make things worse

PSYCHOTHERAPY:

These are difficult psychotherapy patients. They have a lot of turbulent emotion in relation to the therapist, and they act out in ways that endanger them and irritate the therapist. Therapists are tempted to reject or indulge BPD.

It often takes five or more years of intensive individual psychotherapy to resolve BPD.

The therapist must be consistent and reliable, with excellent boundary management.

These patients routinely induce splitting in treatment teams.

They will not progress in therapy if currently being abused; they may under-report or over-report abuse.

These are not cases for the beginner, and student therapists should have intensive supervision when working with borderlines.

A DYNAMIC FORMULATION:

Ego States Theory was developed to explain why some adults intermittently behave like children. According to Ego States Theory, we all start out life as a collection of unintegrated ego states, such as “Happy baby”, “Hungry baby”, “Scared baby”, “Mad baby”, and “Sleepy baby”. We observe normal infants making abrupt switches between these ego states according to their current circumstances, and there seems to be little continuity of memory from one such ego state to the next. We observe normal parents sponsoring integration of ego states in normal youngsters. The preschooler who falls and hurts himself while playing undergoes a switch from the “Happy child” ego state to the “Scared and painful” ego state, and seems to have no idea that his suffering is a temporary condition. Mother provides reassurance along the following lines: “You’re OK now, even though it hurts; you were happy a few moments ago, and you’ll be happy again in another few minutes!” We can later observe the same child in grade school getting hurt, starting to switch ego states, and then reassuring himself that he’ll feel better soon, thereby maintaining his own ego integration. In adulthood, the fabric of ego integration is usually so tightly woven that it takes a catastrophe to cause dissociation of ego states.

Some children, however, don’t have a “normal” childhood with the support of well-integrated parents. Suppose father is alcoholic: he may come home drunk and rape the little girl, and the next day he may not remember what he did. Mother may be physically or psychologically absent from what’s going on with her daughter, so father is her only source of comfort. The child may be unable to get help for a variety of reasons, including her fear of father, fear of losing her father, and a sense that what’s happening is inevitable. She faces an endless series of irreconcilable realities.

Her best defense may be to maintain two distinct ego systems, one of which deals as best she can with father the rapist, the other with everyday living. The defense of dissociation permits the child to avoid thinking about the abuse so she can have as normal a life as possible.

When this sort of childhood starts early and goes on a long time, the ego states may accumulate very different memories, emotions, and behaviors. They may even have different names for themselves: one name representing the angry, hurt, sexually aware part, and the other designating the innocent child in her public persona.

A child growing up in a very sick family system faces a large number of insoluble problems, and dissociation may become the preferred way to deal with virtually every conflict the child faces. Thus, a system of dissociated ego states may arise, one of which does well in school, another is very athletic, a third feels a great deal of rage, a fourth can function sexually, and the fifth goes to church and prays a lot – thus fully expressing all the family values in one person without having to resolve any of the conflicts that divide the family.

Most borderlines report growing up in family environments that were

UNSAFE – abusive, threatening, unstable

DEPRIVING – rather than nurturing

HARSHLY PUNITIVE – often following inconsistent or invisible rules

SUBJUGATING – punishing child’s normal expression of needs and feelings.

Therefore, the borderline patient may usefully be viewed as a collection of relatively unintegrated ego states, whose dysfunctional behaviors and emotions constitute the presenting signs and symptoms. They differ from DID in that complete amnesia between ego states is not seen in BPD as in DID. They differ from PTSD in that intrusive recollections are less prominent in BPD than in PTSD. However, there’s considerable overlap in the origins, signs, symptoms, and effective treatment paradigms for DID, PTSD, and BPD; if you are successful with one of these groups, you’ll likely do well with the others.

I find ego states theory helpful in understanding dissociative disorders, PTSD, and BPD. Ideas about dissociation have become very controversial, however. Many psychologists are strongly opposed to the idea that traumatic memories can be lost and then reemerge. I find these criticisms ignorant, corrupt, and absurd.

They are ignorant in that they persistently confuse dissociation and repression in statements like, “There’s no evidence for repressed memories!” DISSOCIATION is a theory introduced by Pierre Janet, who observed patients with various sorts of hysterical illness to be cured when they recalled traumatic events that were symbolically connected to their symptoms. Janet’s work came before that of Sigmund Freud, who initially endorsed Janet’s ideas, then proposed his own theory of REPRESSION. What is repressed in Freud’s theory is a girl’s unacceptable wish: to replace mother as father’s love object. This wish is both denied and gratified in a SCREEN MEMORY: that father initiated sexual activity with the child. In other words, REPRESSION leads to remembering trauma that never happened, while DISSOCIATION is the forgetting of trauma that DID happen. Any so-called expert who confuses these two antithetical theories is not worthy of serious attention.

Many of the critics of dissociation are corrupt, in that they are associated with an organization that exists mainly to assist persons accused of sexually abusing their children to escape prosecution.

Finally, criticisms of dissociation are absurd, in that they allege that memory is fallible in only one direction. They claim that real trauma can never be forgotten, but that overzealous therapists often create memories of trauma that never happened through their suggestive techniques. These concerns are based on a small number of cases studied by one particular psychologist who observed contrived situations with little relevance to clinical reality.

The “recovered memories” controversy is heated and serious in its implications; it’s well for therapists who treat trauma victims to be keenly aware of the major issues being debated, to avoid hypnotic and other suggestive techniques, and to steer clear of prosecutions based on recovered memories unsupported by other convincing evidence.

THERAPEUTIC TECHNIQUES:

The basic techniques that have been found useful in dissociative psychopathology, whether PTSD, BPD, or DID, emphasize the following common therapeutic factors

1. development of continuity of memory across ego states, leading to improved integration of behavior, affect, sensation, and knowledge

2. a more thoughtful approach to decision making should replace dysfunctional behavior patterns which are impulsive and emotionally driven

3. appropriate expression of affect is facilitated in a therapeutic setting, with attention to parallel development of a repertoire of healthful self-soothing behaviors

4. the patient is encouraged to experiment with new patterns of behavior which will be more effective in getting the patient’s legitimate needs met

5. the patient is given the opportunity to use the therapist as a role model for a more healthy adult lifestyle.

To assist the therapist in maintaining appropriate engagement with borderline patients, a psychologist at Columbia named Jeffrey Young has developed an interesting way of categorizing the ego states commonly seen in borderlines. In his experience, the borderline patient will normally present four ego states, which he calls MODES:

1. The patient normally presents for therapy in an ego state which Young calls The Vulnerable Child Mode – in this mode, the patient is compliant and seeking assistance. This is a continuation into adulthood of behavior patterns used by most children to secure caring and assistance from powerful adults. The therapist will be idealized by the patient in this mode, often leading to a breakdown in normal therapeutic boundaries if the therapist’s grandiosity or guilt can be hooked by the patient. Since the borderline’s need for emotional nurturance exceeds the capacity of even the most giving therapist to satisfy, the therapist who lacks good professional boundaries will often begin to experience anxiety and resentment about the patient’s escalating demands. This will cause a failure of empathy on the therapist’s part, leading to the emergence of

2. The Angry Child Mode – in which the therapist is harshly devalued by the patient. If the therapist reacts defensively, an even more dysfunctional ego state will emerge:

3. The Punitive Parent Mode – since the child was punished for expressing normal needs and emotions, the adult knows that she is wrong to have these needs and emotions, and deserves punishment for expressing her feelings. Because she has internalized her parents’ dysfunctional attitudes and behaviors, she will begin to punish herself for having needed the therapist so much, and for having expressed her anger at the therapist for not satisfying those needs. In the punitive parent mode, the patient will derogate herself during internal dialogues, will experience herself as defective, worthless, and contemptible, and will often punish herself through self-mutilating or self-poisoning. Her attempt to regain a position of emotional equilibrium will often lead to the fourth and last of the common ego states seen in borderlines:

4. The Detached Protector Mode – in which feelings are disavowed, and the patient appears passively compliant and placid. This particular ego state is often overvalued by naive therapists whose personal insecurity leads them to prefer the appearance of calm to the turbulence of the patient’s other ego states.

The Detached Protector Mode is actually the least workable of the four ego states commonly seen in borderline patients; the only appropriate therapeutic technique for this mode is to encourage the Vulnerable Child mode to reemerge. One can do this by reminding the patient how she felt in a previous session.

You may then have to work through eruptions of the Punitive Parent Mode by assuring the patient that her need for nurturance is normal and acceptable. In general, your goal is to extinguish the Punitive Parent Mode by presenting yourself as a more accepting and appropriate parent for the patient.

The Angry Child needs help learning how to express that emotion in nondestructive ways. A therapist who is personally secure will encourage the patient to verbalize even more anger at the therapist, but actual verbal abuse should be redirected into more authentic emotional expressions. In this regard, the patient can be helped to use “I” statements rather than “you” statements – “I felt abandoned by you” rather than “You’re a cold, uncaring, heartless bastard”. You may have to assist the patient to understand that “I think you’re a cold, uncaring, heartless bastard” is really a “you” statement disguised as an “I” statement. The payoff for the patient in learning how to verbalize anger more appropriately is that the patient can then be angry without sacrificing connection with potential sources of emotional nurturance.

The Vulnerable Child Mode is the most workable ego state in borderline patients. Young suggests four basic techniques for this ego state:

1. Cognitive interventions – using journaling, you can teach the patient to examine her dysfunctional thoughts and decide for herself if they are valid. Some common dysfunctional assumptions in borderlines are

a. The world is dangerous and wants to hurt me

b. I am powerless in this world

c. I am hopelessly defective

d. Things are good or bad, choices are all or nothing

2. Experiential techniques – such as gestalt, imagery, and inner-child work

3. Therapeutic relationship – giving the patient a good example to imitate

4. Behavioral pattern breaking – finding new and more effective ways to get legitimate needs met

Some basic therapeutic techniques to use with borderlines:

1. validate needs and feelings; avoid problem-solving for the patient

2. be reliable and caring and real

3. strongly praise any improvement in behavior

4. re-attribute parental rejection to parental defects

5. teach the patient to recognize the various ego-states or modes of behavior as they emerge in the sessions, and to understand how their dysfunctional assumptions arose naturally from their suboptimal early experiences

5. attribute any patient failures to the patient’s excusable misunderstandings and help the patient to analyze these

6. using the empty chair technique, teach the patient how to talk back to the punitive parent

7 acknowledge your mistakes and model forgiveness of yourself and others

Most therapists who write about treatment of post-traumatic syndromes emphasize that treatment must proceed in stages. The first stage is always focussed on the development of a therapeutic relationship based on mutual understanding and respect. Young suggests this stage will be facilitated if the therapist can always think of the patient as a needy, primitive child rather than as a greedy, manipulative opportunist. Emergence of such negative attitudes in the therapist is associated with poor treatment outcomes, as the patient’s original experience with a punitive parent is repeated in the therapy.

It is important that patient and therapist agree on goals for the treatment in language that makes sense to the patient. It will also be necessary for the therapist to make clear the limits of therapist availability. Most patients with BPD have daily and nightly emotional crises, and will need frequent reassurance by phone or in extra sessions, at least until they learn how to manage their emotions better. It’s legitimate to tell the patient that daily phone calls are not OK, and that late night calls make you cranky the next day. You can also mention that learning self-soothing is one of the important goals of therapy.

If the patient is doing something that you can’t tolerate, it’s important to discuss this in session before you reach the point of resenting the patient. It’s appropriate to tell the patient that frequent phone calls disrupt your personal time, and that you may begin to feel resentful if it continues. Borderline patients have usually grown up around people with poor conflict resolution skills and poor interpersonal boundaries, so you want to show the patient how two adults can discuss and resolve a conflict without becoming abusive or withdrawn from each other.

When your practice situation permits, it’s appropriate to inform the patient that you charge for after hours phone contacts as well as for extended phone contacts during office hours. These are professional services which the patient should expect to pay for, just as you would expect to pay for the furnace man to come and relight your burner on a cold winter’s night. Offering unlimited free support at all hours of the day or night is a recipe for therapist burnout and for a major betrayal of the patient’s trust, because you will not be able to keep it up, and a burned-out therapist is both unhappy and dangerous.

Since many of you work for not-for-profit agencies, let me take a moment here to disparage certain dysfunctional attitudes that seem to pervade such organizations. You probably went into this sort of work because you enjoy helping people, and you feel real compassion for those less fortunate. These traits make you willing to work long hours for low pay, and your professional reputation depends on your willingness to go the extra mile for your clients. When an entire organization is staffed from top to bottom with professionals who share the value of self-sacrifice, there’s an opportunity for the best intentions to lead to the worst outcomes.



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