Borderline Personality Disorder

A comment such as "I am so glad that I finally found you. It has been an extremely painful journey with all the doctors I saw before you—they were all terrible!"

is never pleasing to me as a therapist, nor do I ever feel optimistic when the therapeutic relationship begins with this kind of splitting, one of the most important defense mechanisms used by people with borderline personality disorder. I expect this praise to quickly turn into expressions of disappointment and excessive criticism and condemnation at the first moment the client discovers that I will not accept boundary violations and will reinforce the framework of the therapeutic relationship.

Like a swinging clock pendulum, the emotions of people with borderline personality disorder sway from the extreme of "I hate you" to the extreme of "Please don't leave me!" They move through life without recognizing the reality of their emotions and behavior. They may experience episodes of overwhelming anger and periods of severe depression, along with chronic feelings of boredom and emptiness. They may also have a distorted self-image and engage in impulsive behaviors that can sometimes extend to suicide attempts.

Prevalence of borderline personality disorder

Borderline personality disorder is considered the most prevalent personality disorder overall. It belongs to the dramatic-emotional cluster, sharing dramatic behavior and excessive emotionality with narcissistic, histrionic, and antisocial personality disorders.

Although we encounter more women than men with borderline personality disorder in clinical practice, studies indicate that its prevalence does not differ greatly between men and women. This discrepancy suggests that women with borderline personality disorder are more likely than men to seek treatment for it.

More than 90% of people with borderline personality disorder are also diagnosed with other personality disorders, particularly avoidant, dependent, and narcissistic personality disorders. More than half experience major depression, and over three-quarters experience an anxiety disorder at some point in their lives. They may also develop brief psychotic episodes, eating disorders, and addiction.

What distinguishes borderline personality disorder?

• The most distinguishing feature of borderline personality disorder is difficulty regulating emotions. This means that people with the disorder experience emotions intensely and for prolonged periods, and find it difficult to regain psychological calm after an emotionally charged event. Because of their intense emotional reactions, they are described as lacking an "emotional skin."
• Impulsivity, turbulent relationships, and extreme mood changes lead to a considerable degree of instability in relationships , insecurity, and fear of abandonment, as well as a diminished and self-critical sense of self. Difficulty with self-control may lead to dangerous behaviors such as self-harm.
• There is also marked and persistent instability in identity and self-image. People with borderline personality disorder often have no clear sense of who they are or what they believe. They change their preferences, interests, and beliefs according to their circumstances and what they think others want from them. Of course, everyone changes their behavior to some extent in different contexts, but in borderline personality disorder, this shift is deeper and more pronounced.
• Many people with borderline personality disorder also experience difficulty establishing and maintaining healthy personal boundaries. They face challenges in their personal relationships because they do not recognize where their own boundaries end and the other person's boundaries begin.
• Like other disorders, borderline personality disorder is multifactorial, and borderline defenses are described as primitive or immature. Examples include splitting, or alternating between idealizing and demonizing another person, and projective identification, which involves attributing unacceptable motives to others and eliciting behaviors from them that justify that attribution. For example, resentment makes another person hostile, and that hostility confirms that the resentment is justified.

When does borderline personality develop?

According to psychoanalytic theory, borderline personality develops when a mother withdraws love from her child because she cannot tolerate the child's need to separate from her and establish an independent identity. The child never develops the ability to internalize the experience of the mother as both good and bad at the same time. This pattern is then transferred to other relationships later in life. An adult with borderline personality remains angry with the bad mother and continues to fear that the good mother will abandon and leave them. They may now find this dilemma embodied in anyone with whom they interact.

Some believe that child abuse, rather than neglect alone, causes borderline personality disorder. However, not all studies have found a high rate of childhood maltreatment among people with borderline personality disorder. There is also a risk of reinforcing distorted memories in people who are already inclined to justify their behavior by condemning others. Most experts believe that although child abuse and other traumatic events may have some effect on borderline personality symptoms, these experiences alone do not cause borderline personality disorder.

Borderline personality is also associated with bipolar disorder and major depression through one of its central features: an inability to control sudden mood changes. It is difficult to say whether personality causes mood disorders or whether mood disorders shape patterns of thought and behavior that are described as personality traits, such as becoming depressed easily, intense sensitivity to loss, and emotional demandingness. Borderline personality has been described as a disguised form of mood disorder and may be associated with atypical depression or rapid-cycling bipolar disorder.

It has been proposed that all symptoms of depression, mania, and borderline personality should be grouped together as a bipolar spectrum disorder.

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