Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)
Throughout their adult lives, people with borderline PD (BPD) appear unstable. They’re often at the crisis point as regards mood, behavior, or interpersonal relationships Borderline Personality Disorder (BPD). Many feel empty and bored; they attach themselves strongly to others, then become intensely angry or hostile when they believe they are being ignored or mistreated by those they depend on.
They may impulsively try to harm or mutilate themselves; these actions are expressions of anger, cries for help, or attempts to numb themselves to their emotional pain. Although patients with BPD may experience brief psychotic episodes, these resolve so quickly that they are seldom confused with psychoses like schizophrenia.
Intense and rapid mood swings, impulsivity, and unstable interpersonal relationships make it difficult for these patients to achieve their full potential socially, at work, or in school Borderline Personality Disorder (BPD).
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BPD runs in families. These people are truly miserable—so much so that up to 10% complete suicide.
The concept of BPD was devised about the middle of the 20th century. These patients were originally (and sometimes still are) said to hover between neurosis and psychosis—a “borderline” whose existence is disputed by many clinicians Borderline Personality Disorder (BPD). As the concept has evolved into a PD, it has achieved remarkable popularity, perhaps because so many patients can be shoehorned into its capacious definition.
Although 1–2% of the general population may legitimately qualify for a diagnosis of BPD, it is probably applied to a far greater proportion of the patients who seek mental health care. It may still be one of the most overdiagnosed conditions in the diagnostic manuals Borderline Personality Disorder (BPD).
Many of these patients have other disorders that are more readily treatable; these include major depressive disorder, somatic symptom disorder, and substance-related disorders.
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Essential Features of Borderline Personality Disorder
These patients exist in a perpetual crisis of mood or behavior. They often feel empty and bored. Disturbed identity (insecure self-image) can lead them to attach themselves strongly to others and then reject these same people with equal vigor. On the other hand, they may frantically try to avert desertion (it can be actual or fantasied) Borderline Personality Disorder (BPD).
Pronounced impulsiveness can lead them to harm or mutilate themselves or to engage in other potentially harmful behaviors, such as sexual indiscretions, spending sprees, eating binges, or reckless driving. Although stress can cause brief episodes of dissociation or paranoia, these quickly resolve. Intense, rapid mood swings may yield to anger that is inappropriate and uncontrolled Borderline Personality Disorder (BPD).
The Fine Print
The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, mood and psychotic disorders, other PDs)
Josephine Armitage
“I’m cutting myself!” The voice on the telephone was high-pitched and quavering. “I’m cutting myself right now! Ow! There, I’ve started.” The voice howled with pain and rage.
Twenty minutes later, the clinician had Josephine’s address and her promise that she would come in to the emergency room right away Borderline Personality Disorder (BPD). Two hours later, her left forearm swathed in bandages, Josephine Armitage was sitting in an office in the mental health department. Criss-crossing scars furrowed her right arm from wrist to elbow. She was 33, a bit overweight, and chewing gum.
“I feel a lot better,” she said with a smile. “I really think you saved my life.”
The clinician glanced at her nonswathed arm. “This isn’t the first time, is it?”
“I should think that would be pretty obvious. Are you going to be terminally dense, just like my last shrink?” She scowled and turned 90 degrees to look at the wall. “Sheesh!”
Her previous therapist had seen Josephine for a reduced fee, but had been unable to give her more time when she requested it. She had responded by letting the air out of all four tires of that clinician’s new BMW.
Her current trouble was with her boyfriend. One of her girlfriends had been “pretty sure” she’d seen James with another woman two nights ago Borderline Personality Disorder (BPD). Yesterday morning, Josephine had called in sick to work and staked out James’s workplace so she could confront him.
He hadn’t appeared, so last evening she had banged on the door of his apartment until neighbors threatened to call the police. Before leaving, she’d kicked a hole in the wall beside his door. Then she got drunk and drove up and down the main drag, trying to pick up a date.
“Sounds dangerous,” observed the clinician.
“I was looking for Mr. Goodbar, but no one turned up. I decided I’d have to cut myself again. It always seems to help.” Josephine’s anger had once again evaporated, and she had turned away from the wall. “Life’s a bitch, and then you die.”
“When you cut yourself, do you ever really intend to kill yourself?”
“Well, let’s see.” She chewed her gum thoughtfully. “I get so angry and depressed, I just don’t care what happens. My last shrink said all my life I’ve felt like a shell of a person, and I guess that’s right. It feels like there’s no one living inside, so I might just as well pour out the blood and finish the job.”
Evaluation of Josephine Armitage
The first thing this clinician should do is to determine whether the behaviors reported (and observed) had been present since Josephine’s late teen years. From her report of the comment made by her “last shrink,” this would seem to be the case, but it should be verified. These behaviors were pervasive: Her work was affected (calling in sick on a whim), as were her relations with her boyfriend and her previous therapist.
Josephine had an abundance of symptoms. The entire episode of staking out James’s apartment could be seen as a frantic effort to avoid abandonment (BPD criterion A1). Even her initial moments with the present clinician revealed some swings between idealization and devaluation (criterion A2).
She showed evidence of dangerous impulsivity (driving while under the influence of alcohol, trying to pick up a stranger—A4), and she had made repeated suicide attempts (A5). Her mood, even within the confines of this vignette, would seem markedly unstable and reactive to what she perceived to be the clinician’s attitude toward her (A6); her anger was sudden, inappropriate, and intense (A8).
She agreed with a description of herself as an “empty shell” (A7). Although patients with BPD are often described as having identity disturbance and occasional, brief psychotic lapses, Josephine’s vignette gives no evidence of either of these. Even so, she had six or seven symptoms, whereas only five are required.
A long list of other mental disorders can be confused with BPD; each must be considered before settling on this disorder as a sole (or principal) diagnosis. (This isn’t a criterion for BPD, but it is one of the generic PD criteria, as well as one of my personal mantras.) Many patients with BPD also have major depressive disorder or dysthymia.
It’s important to establish that suicidal behaviors, anger, and feelings of emptiness are not experienced only during episodes of depression. Similarly, we need to know that affective instability is not due to cyclothymic disorder. Note that the official criteria don’t mention any of these possibilities, but they are featured in the text.
Patients with BPD can have psychotic episodes, but these tend to be brief and stress-related, and they resolve quickly and spontaneously—all of which makes them unlikely to be confused with schizophrenia. The misuse of various substances can lead to suicide behavior, instability of mood, and reduced impulse control. Substance-related disorders are also often found as concomitants with BPD, and should always be asked about carefully.
Patients with somatic symptom disorder are often quite dramatic and may misuse substances and make suicide attempts. Although this vignette contains no evidence for any of these (other than getting drunk—was this an isolated event?), the evaluating clinician would need to consider carefully the list just given.
Patients with BPD can also show features of additional PDs. Josephine’s presentation was dramatic, suggesting histrionic PD. Patients with narcissistic PD are also self-centered, though they don’t have Josephine’s impulsivity. Patients with antisocial PD are impulsive and do not control their anger; although some of Josephine’s behaviors were destructive, she did not engage in overtly criminal activity.
Finally, dissociative identity disorder is sometimes encountered in patients with BPD. Further interviewing and observation would be needed to rule out this rare condition. Assuming the verification of Josephine’s history, her diagnosis would be as given below. I would place her GAF score at 51.
| F60.3 [301.83] | Borderline personality disorder |
| S51.809 [881.00] | Lacerations of forearm |
There’s no such thing as a late-life PD. By definition, the PDs are conditions present, more or less, from the get-go Borderline Personality Disorder (BPD). If you encounter a patient whose character structure appears to have changed during the adult years, search for the cause until you find it.
Usually, you’ll turn up a personality change due to another medical condition, a mood or psychotic disorder, something substance-related, a cognitive issue, or a severe adjustment disorder.
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