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BORDERLINE PERSONALITY DISORDER BORDERLINE PERSONALITY DISORDER is a pervasive pattern of instability of interpersonal relationships, self image and affect,

and marked impulsivity beginning by early adulthood and present in a variety of contexts.---- DSM-IV (APA, 1994). Patients with borderline personality disorder stand on the border between neurosis and psychosis and they are characterized by extraordinarily unstable affect, mood, behavior, object relations, and self-image. The disorder has also been called ambulatory schizophrenia, as-if personality (a term coined by Helene Deutsch), pseudoneurotic schizophrenia (described by Paul Hoch and Phillip Politan), and psychotic character disorder (described by John Frosch). ICD-10 uses the term emotionally unstable personality disorder. The prevalence rate of the disorder is estimated to be 0.5% - 2%of the general population, 10% of the outpatient treatment population, and 20% of the inpatient treatment population (APA, 1994; Widiger & Trull, 1993). It is twice as common in women as in men (Kaplan and Sadocks Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition). Course & Prognosis: Borderline patients often experience profound dysfunction in many important aspects of life including education, jobs, partner relationships, and marriage. Alcohol and psychosexual problems are also frequent. Repeated suicide attempts and premature death from suicide are frequent complications of borderline personality disorder; therefore suicidal gestures and intentions should be always taken seriously. It has been reported that 8-10% per cent of all persons with borderline personality disorder die by suicide. The long-term outcome of borderline patients has not been studied, but the diagnosis is rarely made in patients aged over 40. It is speculated that neural structures and defence mechanisms mature with age and that these changes, together with social learning, reduce symptomatology. The disorder is twice as common in women as in men. An increased prevalence of major depressive disorder, alcohol use disorders, and substance abuse is found in first-degree relatives of persons with borderline personality disorder. Symptoms:

While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day.5 These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans,

jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone. People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments. People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders. Linehan reorganized the DSM-IV criteria by summarizing the symptoms into 5 categories of dysregulation. Emotional dysregulation: characterized by highly unstable and reactive emotional responses, problems with anger and anger responses, and difficulty with episodic anxiety, depression and irritability. The onset of emotional responses tends to be quick and of a high intensity, and return to normal mood state is typically slow. Interpersonal dysregulation: characterized by intense and unstable relationships often marked with difficulties, and the BPD individuals often engages in frantic efforts to stay in relationships. Behavioral dysregulation: includes extreme and problematic impulsive behaviors such as suicidal or parasuicidal behaviors (deliberate self harm). Cognitive dysregulation: characterized by cognitive rigidity, often in the form of dichotomous or black and white thinking and brief nonpsychotic forms of thought dysregulation, such as delusions and dissociative experiences, often experiences by stress.

Self regulation: which manifests in feelings of emptiness, an unstable self image and low self esteem. Comorbidity with other disorders: Borderline personality disorder is frequently comorbid with affective disorders (major depression, dysthymia, and double depression'), anxiety disorders, somatization disorder, post-traumatic stress disorder, and alcohol abuse. Comorbidity with affective disorders is particularly important. Borderline personality disorder has been shown to be associated with most personality disorders, especially with those from the dramatic cluster. A high prevalence of comorbid personality disorders may be a result of insufficient criteria, or of the underlying borderline personality organization of all severe personality disorders. Differential diagnosis: y major depressive disorder and bipolar disorder, in which there are less affective lability and less impulsivity and often more stable relationships; y histrionic personality disorder, in which there is less self-destructiveness and fewer angry disruptions in relationships; y schizotypal personality disorder, in which psychotic symptoms are less transient and interpersonally driven and in which there is less desire for interpersonal intimacy; y narcissistic and paranoid personality disorders, in which there is relative stability of self-image and less self-destructiveness and impulsivity and fewer concerns over abandonment; y antisocial personality disorder, in which the patient is manipulative to gain profit, power, or material gratification; y dependent personality disorder, in which there are more stable and less intense relationships, and in which the response to the fear of abandonment is characterized by appeasement, submissiveness and the seeking of replacement relationships; y personality change due to a general medical condition. Diasthsis Stress Model: Research into the biological mechanism underlying borderline personality disorder is, although promising, still in its infancy. Most theories suggest that an interaction between an innate biological vulnerability to stress (anxiety, affect regulation) and an invalidating parental environment would cause future borderline psychopathology.

Family studies of borderline personality disorder support the constitutional psychobiological role. There is increasing evidence that parents of borderline patients have a high incidence of affective disorder and borderline-type behaviors, alcoholism, antisocial personality disorder, and other cluster B personality disorders. Depression is common in the family backgrounds of patients with borderline personality disorder. These patients have more relatives with mood disorders than do control groups, and persons with borderline personality disorder often have a mood disorder as well. A strong association is found between histrionic personality disorder and somatization disorder (Briquet's syndrome); patients with each disorder show an overlap of symptoms. Genetic studies: The best evidence that genetic factors contribute to personality disorders comes from investigations of 15,000 pairs of twins in the United States. Among monozygotic twins, the concordance for personality disorders was several times that among dizygotic twins. Moreover, according to one study, monozygotic twins reared apart are about as similar as monozygotic twins reared together. Similarities include multiple measures of personality and temperament, occupational and leisure-time interests, and social attitudes. Organic Causes: Andrulonis et al.reported that 38 % of borderline patients had a significant organic contribution, such as previous head injury, epilepsy, encephalitis, or a history of childhood emotional deficit disorder. They subdivided borderline patients into organic and functional subtypes, and noted that borderline personality disorder would manifest soft' neurological signs. Neurotransmitters: People with BPD appeared to have a characterized lowered function of serotonin, which may be why they show impulsive-aggressive behavior as in parasuicidal acts, such as cutting their arms with a knife. They also show disturbances in the regulation of nonadrenargic neurotranmitters that are similar to those in chronic stress situation as in PTSD. In particular, their hyperresponsive nonadrenergic system may be related to their hypersensitivity to environmental changes. In addition, deficits in the dopamine system may be related to a disposition toward psychotic symptoms. Otto Kernberg: believes that borderlines are distinguished from neurotics by the presence of "primitive defenses." Chief among these is splitting, in which a person or thing is seen as all good or all bad. Someething which is all good one day can be all bad the next, which is related to another symptom: borderlines have problems with object constancy in people -- they read each action of people in their lives as if there were no prior context; they don't have a sense of continuity and consistency about people and things in their lives. They have a hard time experiencing an absent loved one as a loving presence in their minds. They also have difficulty seeing all of the actions taken by a person over a period of time as part of an integrated whole, and tend instead to analyze individual actions in an attempt to divine their individual meanings. People are defined by how they lasted interacted with the borderline. Other primitive defenses cited include magical thinking (beliefs that thoughts can cause events), omnipotence, projection of unpleasant characteristics in the self onto others and

projective identification, a process where the borderline tries to elicit in others the feelings s/he is having. Kernberg also includes as signs of BPD extreme relationships with others; an inability to retain the soothing memory of a loved one; transient psychotic episodes; denial; and emotional amnesia. About the last, Linehan says, "Borderline individuals are so completely in each mood, they have great difficulty conceptualizing, remembering what it's like to be in another mood." Mahler hypothesized that infants at risk are subjected to unpredictable and prolonged separation from their maternal figure during the separation-individuation process of development that occurs around age 18-36 months.9 The unavailability of the maternal figure might make the child forever vulnerable to disorganization brought on by separation experiences. Mahler speculated that the normal developmental process of separation-individuation led young toddlers to experience ambivalence when needing comforting contact with a caregiver. She labeled this period of characteristic ambivalence the rapprochement subphase of the separation-individuation process, roughly spanning the developmental period from 15 to 24 months of age. Researchers observing motherinfant relationships from an attachment perspective have also noted the ambivalent behaviors described by Mahler, as well as a range of other conflict behaviors that become increasingly prominent after 12 months of age. However, recent work on attachment relationships indicates that ambivalent behavior and other forms of conflict behavior centered around the need for comforting contact with mother in early toddlerhood are more likely to be related to difficulties in parent-infant interaction than to normative ambivalence related to a fear of reengulfment, with more conspicuous forms of infant conflict related to the presence of maternal psychopathology. The attachment literature leading to this conclusion is reviewed, including new work on disorganized/disoriented infant attachment behaviors, and recent longitudinal studies of the sequelae of early attachment patterns through age 6. Revisions in the existing framework of object-relations theory are proposed to encompass the new developmental data. Developmental issues: Gunderson, a psychoanalyst, is respected by researchers in many diverse areas of psychology and psychiatry. His focus tends to be on the differential diagnosis of Borderline Personality Disorder, and Gunderson's criteria is as follows in order of their importance:

y y y y

Intense unstable relationships in which the borderline always ends up getting hurt. Gunderson admits that this symptom is somewhat general, but considers it so central to BPD that he says he would hesitate to diagnose a patient as BPD without its presence. Repetitive self-destructive behavior, often designed to prompt rescue. Chronic fear of abandonment and panic when forced to be alone. Distorted thoughts/perceptions, particularly in terms of relationships and interactions with others. Hypersensitivity, meaning an unusual sensitivity to nonverbal communication. Gunderson notes that this can be confused with distortion if practitioners are not

y y

careful (somewhat similar to Herman's statement that, while survivors of intense long-term trauma may have unrealistic notions of the power realities of the situation they were in, their notions are likely to be closer to reality than the therapist might think). Impulsive behaviors that often embarrass the borderline later. Poor social adaptation: in a way, borderlines tend not to know or understand the rules regarding performance in job and academic settings.

Early Learning Experiences: The role of childhood trauma in the development of borderline personality disorder has been identified as crucial in numerous studies. Zanarini et al. (1997) found that childhood experiences of both abuse and neglect were basically ubiquitous among borderline patients, with sexual abuse noted as an important etiological factor in about 60 per cent of severely disturbed borderline patients. Patients with BPD have significantly higher rates of abuse than patients with other personality disorders. Therapy of the BPD can be of the following three types: Pharmacotherapy: though apparently the easiest remedy, this method is hardly effective for the BPD. The usage of antidepressant, antibipolar, antianxiety, and antipsychotic drugs have helped calm the emotional and aggressive storms of some people with borderline personality disorder (Agronin, 2006; Gruettert & Friege, 2005). However, given the numerous suicide attempts by individuals with this disorder, the use of drugs on an outpatient basis is controversial. Additionally, clients with the disorder have been known to adjust or discontinue their medication dosages without consulting their clinicians. Today, many professionals believe that psychotropic drug treatment for borderline personality disorder should be used largely as an adjunct to psychotherapy approaches, and indeed many clients seem to benefit from a combination of psychotherapy and drug therapy (Soloff, 2005; Livesley, 2000). Psychodynamic Therapy: Traditional psychoanalysis has not been effective with these individuals (Bender & Oldham, 2005). The clients often experience the psychoanalytic therapist's reserved style and encouragement of free association as suggesting disinterest and abandonment. The clients may also have difficulties tolerating interpretations made by psychoanalytic therapists, experiencing them as attacks. Contemporary psychodynamic approaches, such as relational psychodynamic therapy in which therapists take a more supportive and egalitarian posture, have proved to be more effective than traditional psychoanalytic approaches (Bender & Oldham, 2005). In such contemporary approaches, therapists work to provide an empathic setting within which borderline clients can explore their unconscious conflicts and pay particular attention to their central relationship disturbance, poor sense of self, and pervasive loneliness and emptiness (Gabbard, 2001; Piper & Joyce, 2001). Research has found that contemporary psychodynamic approaches sometimes help reduce suicide attempts, self-harm behaviors, and the number of hospitalizations and bring at least some improvement to individuals with the disorder (Bradley et a!., 2007; Roth & Fonagy, 2005; Clarkin et aI., 2001).

Dialectical Behavioral Therapy: the most effective intervention method of BPD till date, the DBT was developed by Marsha M. Linehan. The modes for this therapy are: 1. Individual therapy 2. Group skills training 3. Telephone contact 4. Therapist consultation It has two focal points --- Increase of dialectical behavioral pattern, balance versus impulse and dichotomous patterns in thinking and responding  Building adaptive skills in living and relating to others DBT targets behaviors in a descending hierarchy:
y y y y y y y

decreasing high-risk suicidal behaviors decreasing responses or behaviors (by either therapist or patient) that interfere with therapy decreasing behaviors that interfere with/reduce quality of life decreasing and dealing with post-traumatic stress responses enhancing respect for self acquisition of the behavioral skills taught in group additional goals set by patient

Weekly 2.5-hour group therapy sessions in which interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught. Group therapists are not available over the phone between sessions; they refer patients in crisis to the individual therapist. The steps followed here are: Mindfulness: Strategies to increase awareness and self control Interpersonal Effectiveness: Strategies to attain personal goals in interpersonal situations while enhancing self respect and overall quality of relationships Emotion Regulation: Strategies to understand and manage emotions in effective, nonharmful ways Distress Tolerance: Strategies to accept reality and tolerate high levels of painful emotions

The therapist is asked to accept a number of working assumptions about the patient that will establish the required attitude for therapy: 1. The patient wants to change and, in spite of appearances, is trying her best at any particular time. 2. Her behaviour pattern is understandable given her background and present circumstances. Her life may currently not be worth living (however, the therapist will never agree that suicide is the appropriate solution but always stays on the side of life. The solution is rather to try and make life more worth living). 3. In spite of this she needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different. 4. Patients can not fail in DBT. If things are not improving it is the treatment that is failing. The therapist should try to interact with the patient in a way that is: 1. accepting of the patient as she is but which encourages change. 2. centred and firm yet flexible when the circumstances require it. 3. nurturing but benevolently demanding. The dialectical approach is here again apparent. Reference: Abnormal psychology, Ronald J. Comer, 7th Edition Kaplan and Sadocks Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition Oxford Textbook of Psychiatry