Did you know that the month of May is Borderline Personality Disorder Awareness month?
Borderline Personality Disorder (BPD) is sometimes referred to as the “untreatable disorder.”
Patients with BPD suffer from distortions in cognition and a sense of self which can lead to frequent changes in all aspects of social life.
Patients with personality disorders exhibit chronic problems with people in various contexts, including therapists.
As a result, people with the disorders often don’t seek treatment. Patients with BPD most often quit treatment programs about 70 percent of the time (Beck, A. & Freedman, A, 2003).
Some patients with BPD will feel they are unfairly misunderstood or mistreated and with a history of trauma exposure, i.e., abuse, neglect, domestic violence, or other complex trauma feed the intensity of anger, depression, and anxiety which unlike those with depression or bipolar disorder will only last for a few hours. However, these symptoms are exacerbated when the patient feels isolated and lacking in social support. These feelings can result in frantic efforts to avoid being alone even when the partner they chose is abusive to them.
Once in a relationship, the individual with BPD will begin to sabotage the relationship when the fear of being hurt arises. Patients with BPD are sometimes referred to as a “black widow” because they have a way of giving attention to a relationship with the desire to feel wanted and then out of fear of being hurt will fall into the fight/flight response.
Symptoms of BPD
Borderline Personality Disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adult and present in a variety of contexts.
- The patient will present frantic when perceiving real or imagined abandonment.
- The patient will present with a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- The patient feels confused and has a lack of sense of self and low self-worth.
- The impulsivity in the patient’s life will act out in self-damaging behaviors, i.e., spending, sex, substance abuse, reckless driving, or binge eating. There may be recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- The patient’s affective instability is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.
- The patient reports chronic feelings of emptiness and inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
With all of these symptoms and the transient lifestyle, the patient leads along with stress-related paranoid ideations or severe dissociate symptoms make it very difficult to treat this personality disorder (American Psychiatric Association, 2013).
Complex Trauma and BPD
Herman, Perry and van derKolk (1989) conducted research that revealed there were significantly more borderline subjects (four out of five) who suffered childhood traumas such as physical abuse, sexual abuse, or the witnessing of serious domestic violence.
Research showed that it was less common for patients with borderline traits to have undergone childhood traumas, and least in the non-borderline subjects. However, a strong link exists between the history of abuse in childhood and a diagnosis of borderline personality disorder.
The trauma-exposed patient will many times present with an AXIS II of Borderline Personality Disorder or w/Borderline Traits.
With a good trauma assessment and clinical interview, which includes a thematic analysis of the patient’s life story, it will be easy to detect the underlying cause of borderline traits or the diagnoses of Borderline Personality Disorder.
Below is a case example of a patient who struggled with mental illness, e.g., mood disorder, borderline personality disorder, and substance abuse, due to a history of complex trauma from sexual abuse (McFeature, B. & Herron-McFeature, C., 2017).
Lilly had a history of repeated sexual abuse, raped by her stepfather reportedly nightly, from age five to seventeen.
Reportedly, her mother did not believe this was happening and told her she was making it up. She clearly did not trust anyone and had little emotional attachment.
Furthermore, she had begun to prostitute herself to obtain rent money, drugs, and alcohol.
She was referred to a primary care clinic for a physical and was diagnosed with Hepatitis C. She was placed on medication to address the Hepatitis C and was then scheduled for a mental health assessment by the clinical psychologist on staff at the primary care office and available for a same-day visit.
She reported to the behavioral health provider that her daughter was in foster care and that she also had some suicidal thoughts.
Upon the completion of the assessment, it was revealed that she used alcohol in access, trusted no one, and was not interested in any men in her life, except to use them to get money.
She also reported a history of self-harming behaviors and several suicide attempts resulting in psychiatric hospitalizations.
The primary care physician had prescribed Interferon for the treatment of the Hepatitis C. Because Interferon has been shown to cause liver issues, it is not prescribed to a patient who is using drugs or abuses alcohol.
Lilly had not shared with the PCP her drug of choice, “alcohol.”
Along with AXIS I diagnosis, Lilly was also diagnosed with Borderline Personality Disorder upon completion of his assessment.
He had a discussion with her about the medication and that if she thought that she was not able to control her alcohol consumption that she should inform the PCP to discuss her medication options.
The note was placed in her electronic record, and the PCP was alerted to the patient’s alcohol abuse.
Had Lilly left the clinic and began taking the medication prescribed in combination with her illicit drug and alcohol use, she would have placed herself at risk of further liver damage.
As a behavioral health provider, it is critical that clinical assessments include aspects of the patient’s overall health.
The complexity of working with a patient diagnosed with BPD can be difficult on many levels.
Dialectic behavior therapy (DBT) is a modification of standard cognitive-behavioral techniques designed specifically for the treatment of BPD (Block, M.J., Westen, D., Ludolph, P., et al., 1991).
DBT was developed as an outpatient treatment modality, but it has recently been modified for use in hospital settings as well.
DBT focus is to help the patient be more mindful of daily life experience, learning interpersonal effectiveness, ways to produce emotional regulation, and finding better ways to build a tolerance to distress without impulsivity.
BPD has been considered “untreatable,” however if untreatable then healing must occur with a care plan to manage the symptoms.
Lack of trust is at the core of this disorder while trust is the foundation for healthy relationships.
The patient must have an opportunity to experience successful relationships which have the ability to demonstrate love and trust.
Sadly many times human beings hurt one another because they were hurt. In some cases self-medicating with drugs and alcohol is utilized by the patient to cope with the emotional pain.
Without treatment interventions and ongoing support it is extremely difficult for relationships to exist in authenticity and unconditional love.
- Young women, ages 18-28
- Dual diagnosis, with an emphasis on mental health
- Primarily borderline personality disorder
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Cinthia McFeature, Ph.D.
Beck, A., & Freedman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford.
Block M., Westen D., Ludolph P., et al. Distinguishing female borderline adolescents from normal and other disturbed female adolescents. Psychiatry. 1991 Feb. 54(1):89-103.
Herman, J., Perry, J., van der Kolk, B. Childhood trauma in borderline personality disorder. American Journal of Psychiatry. 1989 Apr;146(4):490-5.
McFeature, B. & Herron-McFeature, C. (2017). Integrated health – HeartPath practitioner assessment and intervention for the trauma-exposed patient. Melbourne, FL: Motivational Press, Inc.
Verheul, R., Van Den Bosch L.M., Koeter, M.W., De Ridder, M.A., Stijnen, T., Van Den Brink, W. ( 2003). Dialectical behavior therapy for women with borderline personality disorder: 12- month, randomized clinical trial in The Netherlands. British Journal of Psychiatry, 182, 1 35-40.