Sunday 8 October, 2006

Dealing with borderline personality disorder

Posted in Emergency Dept., General Practice, In The Field, May Su, Psychiatry at 21:31 by May Su

Original article: May Su :: Printer friendly

There is the hypothesis that borderline personality disorder may not be a true personality disorders but rather a form of post traumatic stress disorder. Regardless, a person with borderline personality disorder will present with particular characteristic traits which can be difficult to manage.

Borderline personality disorder

Characterized by: instability of mood, poor self-esteem and self-image, and poor impulse control (1). These mood fluctuations may occur over the space of hours or days, as opposed to the mood fluctuations that occur in bipolar affective disorder. There is often a great fear of abandonment, and higher sensitivity to rejection (or perceived rejection). This can manifest as more unstable interpersonal relationships. The term “splitting” refers to these intense by transient relationships, which can suddenly switch from idealization to contempt.

A person with borderline personality disorder can be incredibly charismatic and witty and enjoyable to be around. Beware of the patient who is overly effusive regarding your abilities. It can be a sign of splitting.

In the doctor-patient relationship splitting can be very problematic, as miscommunication is more like to occur in this setting. Team communication even to the point of regular case meetings, becomes even more important when “splitting” is occurring.

Patients with borderline personality disorder certainly have a higher rate of self-harm without suicidal intent, and in addition a higher rate of suicide attempts (unfortunately sometimes successful).

Epidemiologically borderline personality disorder is much more common in women (ratio of 4:1), and there is often a history of childhood trauma. It is difficult to make a diagnosis of borderline personality disorder prior to the age of 18 years, due to the other developmental changes occurring at this time. It is also extremely uncommon for a first diagnosis of borderline personality disorder after the age of 40 years. This may reflect the evolution of borderline personality disorder into more stable personality disorders, or it may mean that patients with borderline personality disorder may stop seeking help as they age.

Techniques useful in dealing with the borderline personality disorder

Historically, the treatment of patients with borderline personality disorder has been difficult (2).

The aim is to minimize and limit aggression and impulsivity via conflict resolution and psychotherapy. Limit setting is especially important in this setting. Be cautious of splitting.

Inpatient care is not generally indicated, unless there are clear cut treatment goals. There are concerns that prolonged inpatient stays can increase the risk of psychosocial dependence, and in fact increase the risk of regression, and thus self-harm. However there must be access to appropriate hospitalization for periods of severe regression or heightened suicide risk.

Things that can assist with inpatient care:

  • Adequate communication between team members;
  • if inpatient stay is required, there should be clear goals for why the person is admitted and a plan for when to discharge. Short stays are preferable;
  • firm limit setting – verbal and physical abuse is never to be tolerated;
  • be consistent – For example, if you have told the patient that they will have to have a “time out” for verbally abusing staff, then they must have a “time out”;
  • safety – removal of potential implements for self-harm;
  • inform the community team on discharge, as the majority of care is often outpatient;
  • it would also be helpful at this time to have a plan for further management, whether dialectic behaviour therapy, or for crisis intervention only.

The mainstay of treatment is long-term treatment with an appropriate therapist in individual and/or group psychotherapy.

Dialectic behaviour therapy

Dialectic behaviour therapy (DBT) is a modification of standard cognitive behavioural therapy, and was designed specifically for treatment for borderline personality disorder. Currently, DBT is the only therapy proven to be effective for treatment of BPD.

The focus of DBT is to teach patients 4 skills:

  1. mindfulness (attention to one’s experience);
  2. interpersonal effectiveness (predominantly assertiveness);
  3. emotional regulation;
  4. and distress tolerance without impulsivity.

The main difficulty is that the person has to be willing to change and able to interact with cognitive behavioural therapy.

Limited value of medications

Often by the time that a patient presents to a clinician that have often tried a myriad of therapies such as antidepressants or antipsychotics. Possibly there may be a faster response with concurrent therapy with dialectic behaviour therapy and treatments such as selective serotonin reuptake inhibitors (SSRIs), however there is limited benefit in treating BPD with medication alone.

Unfortunately there has been variable effectiveness with case management, and although certainly this can be helpful for some patients, it is not true for all.

Reference articles

(1) Borderline Personality Disorder. National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services. January 2001 NIH Publication No. 01-4928. [Link]

(2) Finley-Belgrad E., Davies J. Personality Disorder: Borderline [electronic article]. Emedicine. Last updated 3 May 2006. [Link]

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16 Comments

  1. Just Me said,

    Validation is the single most important thing in “dealing” with a client with borderline personality disorder.

    We walk around feeling invalidated all the time — whether it is happening or not. I believe this rises from extremely low self esteem combined with the natural reaction of those around us from the behaviors we exhibit.

    My experience has been that while traditional talk therapy has been useful in terms of gaining insight and feeling supportive, and that while behavioral therapy has addressed some of my issues, it took dialectical behavioral therapy and the accompanying skills training to make a dent in the deep layers and level of anger I feel.

    As you know, one of the tenets of DBT involves having an extremely patient and deeply caring therapist who is more involved in a client’s life than is traditionally “acceptable.” This includes being available by telephone for both coaching and soothing. My experience has been that I tested this availability at first, but have gradually come to use it for its intended purpose: To help coach me through a discrete episode of impending dysregulation and to talk me back into regulation when I have imploded.

  2. May Su said,

    Thank you for your well written and well thought out comment. I appreciate that life is often very difficult from the other side of the fence (as the person receiving treatment), and it was helpful to get your perspective (fortunately for you, a positive one) and your experience with DBT.

  3. -gains- crusted said,

    Individuals in mh services, may have no formal education dealing with BPD, or the causes.

    BPD individuals move ahead in therapy, and the BPD individuals’ quickly invalidated by the workings of generic employees of mh programs or services.
    Then what!

  4. Michael Tam said,

    Interesting perspective -gains- crusted, but your nihilism aside, the world does not revolve around people with borderline personality disorder. One of the important parts of treating any PD is firm and realistic limit setting; people must learn to accept and deal with the fact that everything including their therapist and therapy have limits.

    Regards.

  5. Dealing with Borderline really brings up the importance of recognizing what emotional validation means. It means acknowledging that the other person’s feeling has validity from THEIR standpoint, but at the same time is not mutually exclusive with setting limits and boundaries in the external world. This is why in I Hate You, Don’t Leave Me, we must empathize, and then also, afterwards, share truth. The ability to walk this tightrope is the key to dealing with not only Borderline, but many other situations of conflict.

  6. Brenda said,

    HI, I am a mom with a 26 year old daughter who has recently be diagnosed with BPD and Post Traumatic Stress Symptom. We have had a rough relationship for years, up and down. She loves, then holds me in contempt. I am trying to learn what I can do to help and recognize when she is in a rough stage (she is charming most of the time). I dont know what I can do as a parent to help. For years I thought she had Bipolar disorder and urged her to get help for which she resented me. She has three children who she loves. She lives with my husband and I. She had a Christian uprbringing and I have stood by her through thick and thin but probably damaged her during her rough tmes by not know what this is or how I can help. She has been married three times to me who just got out of prison. The marriages didnt last long. I dreaded that the kids had to go through it. I voiced these opinions. Her first ex just got out of prison again. He maxed out his term. He is an obsessive liar and he is back in her life as a “friend”. I voiced that I don’t understand why he wants to be around thekids o why she lets them (They are not his.) She has dated several other unsavory characters of which I tried hard not to say anything, just pray. But I just made plain that I didn not feel it is good to let him back into her life or the kids life. My hustband and I just went away for a couple of days. We very rarely do anythign without them. They were fine when we left but then I had a sense of impending doom. She called me shortly into the trip, crying and upset becasue she had just slept with her last ex again and had talked with his girlfriend and she told her that she had HIV. I told her not to worry, that the chances were slim that she had it and she is being tested. She called a doctor and they verified. Then she called to tell me she ripped her toe open. Then she called to see if she could go out right when we got back and if I would watch the kids. I tred to compromise and said, give me a couple of hours to rest, but it was a no go…she had to go right then becasue she had ride. I said, if she waited until next weekend I would give her a ride and watch the kids. She packed them up to leave and told me that she wouldnt be home all night. She said she would move just as fast as she could and inferred another township. I said, why do you want to do that, if you want to move, why not to the same township so that the boys who all have learning disabilities to some extents and are in very good programs, who know their routines and have friends. I said, if you move them and keep making these kind of decisions they would grow to resent her. She took it that resent means despise and I couldnt clarify. She then let into me that I try to control her, which is probably true to some extent because I have tried to sit on her when she is making bad choices like her last husband. She told me I disgust her and then I needed to treat her like an adult and yet I treat her like she is 12. I told her sometimes she acts like it. And she told me hat she would have her first x in her life that he was her friend and she would allow him around her kids but that she would keep them away from anyone who fills their heads with negatives. I said
    Do you really think I would do that?” and she said “You do it without realizing that you do it.” and that I disgust her and yada yada. I try not to get hurt at these times. I do worry about the kids. This first x has been repeatedly sent back to jail, is an accomplished liar, has kissed the blarney stone, and has claimed that his father abused him which his mther denies. I worry about the kids. I would love her to get her own place, but not at the expense of the children having to change schools. The oldest has PDDNOS and it would bother him to move from my house and from the school district. Alot. I apologized to her that I made her feel like she was 12 and told her that I thought she had a loving heart and could be the best of friends and that she was a good mother. I said I dont understand where some of the words she spoke came from. But yes, I did try to sit on her sometimes when I thought she was making bad mistakes. I wanted to scream “How can you choose an x husband, x con over me, who has been there when you have written bad checks, gotten into trouble, etc..” But I just tried to realize that she was having a rough moment and that she doesnt really mean it at me, that she loves me. My husband and I have always loved and taken care of her and her brother. I found out when she was nine that a teen, highly recommended babysitter at an army base, had abused her when he watched her for 2 afternoons. I had know Idea. He was gone at that point and I could not pursue it. But she dreamt about it over and over. He had offered her a stuffed animal if she let him touch her. She felt really guilty. I bent over backwards assuring her that she was okay, that it wasnt her fault. I wanted to take her to counseling but she would have none of it and since we went to regular bible fellowships,I thought that was enough. Apperntly not. I wish I had made her get counseling but I didnt. She also had a severe head injury when she was 3 years old. Brain fluid leaked out of her skull under the skin on her forehead and then went back in 3 weeks later. She got kicked out of highschool for drinking and I tried to homeschool her but she hasnt finished…she has 5 exams left in Biology. I feel like I have walked the tightrope for years that is entailed in this thread without knowing what it was or why. She only gets really bad every three months or so, which is too much, but she was also drinking this weekend while we were gone which sometimes inflames these rough patches. I am nto sure what to do or how to do it for her. I need some really good direction to try and help. But at the same time, she makes it clear she resents my meddling or as she puts it, my controlling. I do try to warn her before she does something impulsive and bad for herself. Sometimes she listens but usually moves heaven and earth to get what she wants and then we weather the storm and then I help pick up the pieces. Any suggestions?

  7. kathleen said,

    I have tears for you after reading this. what to do specially when there are children involved. I am a child of a mother who was mentally ill. I am almost 60 years old now. One thing I know for sure is you have no control over your daughter. you do have control over yourself and your actions. The hardest thing of all is to drop the ego. That will help you stay rational at really crazy times. set limits and stand by them. YOU TAKE THE STiRING WHEEL . just as you would automatically crab a small child that runs into traffric or harms way. amazing she will respond. and it does get easier. no arugument no reasoning…set the rules and stand by them. document what you need to if someday there is a need to have legal control of the children. please help stop the cycle.

  8. harry said,

    i fell in love with a girl who has BPD and im still with her. i dont know if its a good idea to move in together or not, as its what we want, we think we’ll be happy and all but will being away from the emotional triggers at home change the PD at all? any suggestions?

  9. Denwar said,

    I’ve been engaged to a BPD girl for 5 years and although I love her, it’s been extremely stressful and a lot of hard work.
    I think the relationship has survived only because of my own efforts to make it survive.
    She tells me she loves me but I really don’t know whether to believe her?
    It seems like I’m a full time carer/slave, rather than a partner/husband.
    I don’t have anyone to talk to because she doesn’t let me have any friends, I also don’t see my family much for pretty much the same reason.

    My only advice would be to take things slow with a BPD lover and have an escape plan, that sounds harsh but I mean keep some personal savings in case you need to move out.

    In my case; I’ve made a commitment to her and I have to stick by that, regardless if I’m happy or not.

  10. Denwar said,

    Oh yeah, beware that her BPD will affect you eventually: stress, anguish, hurt, depression.

    “We can’t help, Who we fall in love with!”

  11. Toast said,

    MY advice to anyone involved with anyone even close to having BPD is to run and never look back. I married such a person several years ago and am drained, sad and angry at myself (and her). She managed to destroy my friendships, family relationships, our finances.. all the usual stuff. Putting in place firm boundaries doesn’t help. 4 years of counselling only helped her validate the fact that she is right and the world is wrong. She believes that she has a right to her behaviousr, because she is simply reacting…. Stupid me – 4 different psychologists telling me to get out, and somehow I hoped the next one would help her. Now we have a child who suffers at her hands. I’m finally moving on and getting ready for the court fight and more of her lies.

    God Bless

  12. harry said,

    thanks for your replies. i think you’re all right really, as its so subjective a problem. my partner is convinced she’s a very bad person and nothing i can say or do can stop that for some reason. starting to realise that i can only really make her distracted from that thought, but it always comes back eventually, then she’s ok after that, but not for long, regardless of who she’s with. maybe i should just cut and run now, but if i do then i’ll never get to at least try to live with her and make it all work better than it is now.

    is it wrong to sacrifice large parts of your own life to make another’s, whose suffering is intense, a bit happier?

  13. Lisa said,

    Hello. I’ve been googling through personality disorders trying to find one that matches my father’s personality and the closest it comes to is BPD.

    Here’s our story:

    My father (in his 50s) is a very helpful, very friendly, very protective person with overly good morals and christian beliefs. He grew up as the middle child of 8 siblings. He married my mom who was very understanding and a quiet person.

    While growing up my father was very protective of my brother and myself. He always put us first, even quitting his job just to take care of us and ultimately become the house-husband. However, earlier in his short working life he impulsively quit his jobs due to problems with interoffice relations between co-workers. Being asian in an all-white country during the 60s-80s was very difficult for him. He would come home and complain to mom about his workmates etc. Although he was a a good father always teaching us and helping with assignments, he would snap and lash out at mom many times about how bad his life would turn out and get angry with even the smallest comment mom or someone else would say, which we would always overhear and even if we were only children at the time, we always knew mom never did anything that wrong to deserve such violent verbal bashings.

    This went on throughout grade school, high school, and until out recent university years. Due to having only a single mode of income, we lost two houses over those years and things became financially hard for us (although dad was on some kind of sickness benefit from having medical problems when we were young kids – which he also blamed for not being able to work since I was in grade school). A few years ago we supported his major surgery on his spine. Our lives revolved around his recuperation, which he doesnt even acknowledge now.

    To cut it short, my mom passed away recently from cancer. While on chemo, my dad was in his own world addicted to the internet since his operation, and tried to lighten our moods the wrong way by making jokes on how mom looked since she started chemo. My brother and I spent all our free time not at work with mom, upstairs in her room and trying to take her out. Dad would pick faults with people and especially my brother who forced my mom to get him to break up with his girlfriend, which he did. Dad would constantly nag my mom and I about my brothers situation and how he would always come home late on weekends (baring in mind my brother is already nearly 30 yrs old). My brother would always answer him back, my father did not realize why we would answer back. He didnt realise that his verbal abuses torward mom growing up is one of the reasons why.

    During the time of her hospitalisation and death, close relatives who grew up with mom came from overseas to visit mom for a few weeks. My dad didnt cope well while we had people in the house. He acted differently, like overly friendly, but then he would complain to me constantly about their ways, attitudes and how they spoke. A small feud occurred regarding religion because they were catholics and we are not. Anyway, in short dad felt like mom’s relatives were against him and was jealous why my brother and I got along with them so well. He hates it when we give things to relatives. They asked if they could do a prayer their way, my dad didnt say no like he should have, so they went ahead with it. Once the prayer started dads face fumed and he left my mom’s hospital room.

    Because my dad nagged and nagged about how mom’s family was evil and were sorcerer’s, after the relatives returned home, me and my brother decided we go on a trip to dad and mom’s mother-country. Dad didnt want to and fumed because he had lost his pride and said they disrepected him (which i do agree with somewhat), but saying that they look down on him blah blah was not true. After dad’s reaction to this, we found cheap tickets which we ended up buying. Knowing he didnt want to come, we decided we would go for 10 days and thought dad would be ok on his own, because he was acting too weird and kept talking about evil people etc.

    After the trip, w came back and dad didnt like how we responded to him upon arrival so he locked himself away from my brother and I for 3 months. His only contact with the oustide world was the internet, email and few phone calls to his siblings who would also try to get trhough to him by telling him off which he did not like.

    So now he is talking to me, but the same conversation about evil relatives and distrusting the world keep coming up even if i try to change the conversation. I am now in between my brother (who refuses to speak to him now – i dont blame him) and my father. I try my best to understand dad, but I snap as well behind closed doors to release my anger about the terrible things he says and keeps over-analysing.

    I truly need some help with how to handle him. If there is anyone there patient enough to read this far in my letter, could you please send me some advice?

    There’s so much negativity, self-pity and hate in his mind and heart. He hates everyone my brother and i are close to (especially relatives). He constantly tells me how to do things and wants things his way. He overanalyses people we converse with, doesnt enjoy watching tv as he has a comment toward people on the tv, he only enjoys spending time in front of the computer, and wonders what he did wrong in his life to receive such distance from me and my brother.

    I love him, but i need help/advise with his personality disorder.

  14. Michael Tam said,

    At some level, people choose to live, the way they want to live. If there are aspects of your father’s life that are distressing for him to the degree that it bothers him, then he should discuss this with his General Practitioner.

    BTW, from the description in your story, it does not sound like your father has borderline personality disorder.

  15. Lisa said,

    Hi Michael Tam,

    Thanks for replying. I re-read what I posted and realized that it doesnt sound like my father has BPD. There were just too many memories to put all at once and I wanted to emphasise the situation now, which is that he did not handle the situation of mom’s passing and having people stay at our house. There are many many memories of him being angry, throwing verbal tantrums then hiding in his room for days to months then suddenly comnig out and acting like nothing had happened. He constantly criticises everyone and everything, no one is perfect. When he talks to people outside of our immediate family, he acts completely different, as in overly friendly, changes his tone of voice to become more articulate (but sometimes it gets really embarassing), he gets angry and snaps with little things ie. if you say something to him he doesnt agree with, he will overanalyse conversations he had and past memories over and over again almost everyday of hi life, hence his life including my brother’s and mine are completely stagnant. He always looks at the bad in people, very stubborn, very anal at times with house work and washing his hands etc. He thinks people in his circle, friends, family and us are out to get him. He is overly jealous that we are close to relatives (ie. cousins, aunts, uncles). Always talks about himself positively and no one is better than him.

    Are all these annoyances which he has never changed or admitted to sound like BPD?

  16. Michael Tam said,

    As before, it does not sound consistent with borderline personality disorder. If there are aspects of your father’s life that bothers him, he should bring it up with his regular doctor.

    I would also add at this point that it is generally a BAD idea to make internet diagnoses for yourself or for family and friends.

    Your description of your father paints a picture of someone with narcissistic personality traits but it would be quite impossible for a clinical diagnosis to be made on a story alone.


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