What does borderline personality disorder look like?
Dr. Yeomans: Those with the disorder have extremely intense emotions that can shift rapidly from a negative, depressed state to an elated one, but with a predominance of negative feeling states. In this psychiatric illness, the extreme and intense mood swings often are precipitated by reactions to events (“trigger events”) that are disproportionate to the event and that someone else might take in stride. The illness is also characterized by rejection-sensitivity, chaotic relationships, and an overall difficulty in managing emotions.
For example, if a boyfriend or girlfriend does not return your call, instead of being annoyed and moving on, the combination of dejection and anger in a person with borderline personality disorder could possibly lead the person to cut their own wrists. Such destructive actions, usually of an impulsive nature, are a way of putting intense feelings, like rejection and anger, that you can’t tolerate, into action in an attempt to discharge the emotion rather than to continue to feel its intensity. The behavioral manifestations of intense emotions, in addition to self-cutting, include substance abuse, eating disorders, and sexual promiscuity — dramatic ways of behaving that stem from not being able to manage emotions.
In discussing disorders that involve changes in mood, it is important to make clear that not all depressed states indicate a psychiatric condition. If your spouse walks out on you or you lose a parent, it’s normal to feel depressed. In such cases, the depression may be an ongoing, terribly low, dejected mood but is appropriate to the circumstances. The borderline person demonstrates more reactivity to relatively minor events and demonstrates contradictory emotions that erupt over a short time.
How does borderline personality disorder affect relationships?
People with borderline personality disorder have relationships that can be chaotic and intense, veering between a desperate neediness for others to an intense anger or dismissal of others when feeling rejected, even in situations where the other person may in fact be neutral or even positive. Individuals with borderline personality disorder have difficulty accurately reading people’s emotions and trusting others. There is a difficulty with how the individual perceives others. Once, when a borderline patient told me a sad story that brought tears to my eyes, he became very angry because he was convinced that my tears, rather than an expression of empathy, were my way of mocking.
Where does the behavior stem from?
It comes from a combination of an emotionally charged temperament and the lack of a solid sense of self. Without a clear and coherent identity, the individual depends on what’s happening around them to determine what they feel and what they do.
What is the cause of this disorder?
There is no single cause of borderline personality disorder, though studies suggest that certain traits, especially a temperament characterized by intense emotional reactions, stem to a large degree from genetics.
Developmental factors, including problems with emotional attunement between a developing child and caregivers, seem to play a role, as do physical or sexual abuse, or emotional neglect. However, it’s important to note that in cases with a history of trauma, the disorder seems to stem from a combination of temperament and trauma rather than trauma alone, since many people who have experienced trauma early in life do not go on to develop serious psychiatric illnesses.
How is borderline personality disorder treated?
There is no medication that successfully treats the condition, although they may help reduce some specific symptoms, such as intense anxiety. Evidence-based models of psychotherapy are the treatment of choice. Dialectical behavioral therapy operates from the assumption that those with borderline personality disorder lack skills necessary to tolerate intense emotions or thoughts.
Transference-focused psychotherapy emphasizes the observation and interpretation of patient behavior in the relationship with the therapist to help identify unrecognized or distorted internal emotional states that are activated in relations with others and then to integrate them into a more coherent sense of self that includes emotional balance.
Mentalization-based therapy similarly helps individuals recognize their mental states and be aware of them in their relations with others.
Good psychiatric management is based on a case management model that combines a focus on the environment of the patient, psychoeducation, supportive therapy, and possibly family therapy.