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Approximately 10 percent of psychiatric outpatients and 20 percent of inpatients, and between 15 and 25 percent of all patients seeking psychiatric care, are diagnosed with the disorder.
If the people in these short profiles seem inconsistent, it should not be surprising—inconsistency is the hallmark of BPD. Unable to tolerate paradox, those with borderline personality are walking paradoxes, human catch-22s.
As many as 70 percent of BPD patients attempt suicide.
When explored in depth, however, the nine symptoms are seen to be intricately connected, interacting with one another so that one symptom sparks the rise of another like the pistons of a combustion engine.
four primary areas
A borderline individual suffers a kind of “emotional hemophilia”; she lacks the clotting mechanism needed to moderate her spurts of feeling. Prick a passion, stab a sentiment in the delicate “skin” of a borderline personality, and she will emotionally bleed to death.
This type of behavior, referred to as “splitting,” is the primary defense mechanism employed in BPD. Technically defined, splitting is the rigid separation of positive and negative thoughts and feelings about oneself and others; that is, the inability to synthesize these feelings.
However, more recent epidemiological research confirms that the prevalence is similar in both genders, although women enter treatment more frequently.
After sixteen years of follow-up, 99 percent of borderline patients achieved at least two years of remission and 78 percent experienced an eight-year remission (defined as no longer fulfilling five of the nine defining criteria).
In contrast, state disorders (such as depression, schizophrenia, anorexia nervosa, chemical dependency) are usually not as enduring as trait disorders.
Criterion 1.
Criterion 2.
Criterion 3.
Criterion 4.
Criterion 5.
Criterion 6.
Criterion 7.
Criterion 8.
Criterion 9.
Studies indicate that approximately 42 to 55 percent of BPD features are thought to be attributable to genetic influences, the rest derived from environmental experiences.
Oxytocin, sometimes dubbed the “love hormone,” for its association with maternal bonding, increased socialization, and decreased anxiety, may be dysregulated by BPD.
In perhaps an oversimplified way, this suggests that in BPD, the evolutionarily more developed, reasoning, “rational” part of the brain is overwhelmed and unable to control the more primitive, instinctual, “impulsive” portion of the mental system. (Similar imbalances are observed in patients suffering from depression and anxiety.)
Mahler divides separation-individuation into four overlapping subphases.
Not all children who are traumatized or abused become borderline adults, of course; nor do all borderline adults have a history of trauma or abuse. Further, most studies on the effects of childhood trauma are based on inferences from adult reports and not on longitudinal studies that follow young children through to adulthood.
Borderline personality disorder is the only major psychiatric illness for which there are more evidence-based studies demonstrating efficacy from psychosocial therapies than for pharmacological (drug) treatments. Thus, unlike the treatment for most other disorders, medications are viewed as secondary components to psychotherapy.
Cognitive and Behavioral Treatments
Dialectical Behavioral Therapy (DBT)
The dialectic of the treatment refers to the goal of resolving the inherent “opposites” faced by BPD patients—that is, the need to negotiate the patient’s contradictory feeling states, such as loving, then hating the same person or situation.
Systems Training for Emotional Predictability and Problem Solving (STEPPS)
Schema-Focused Therapy (SFT)
Psychodynamic Treatments
Transference-Focused Psychotherapy (TFP)
Mentalization-Based Therapy (MBT)
Good Psychiatric Management (GPM)
In these studies, tracking borderline patients over a ten-year period, up to two-thirds of the patients no longer exhibited five of the nine defining criteria for BPD and therefore could be considered “cured,” since they no longer fulfilled the formal DSM definition.
Change is a monumental struggle in BPD, much more difficult than for others because of the unique features of the disorder. Splitting and the lack of object constancy (see chapter 2) combine to form a menacing barricade against trusting oneself and others and developing comfortable relationships.
