What is Borderline Personality Disorder? The Fragile Ego!!

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Borderline personality disorder (BPD) is a complex syndrome and is believed to affect the individual in various domains. The prevalence in the general population varies from 1.5 to 2% and BPD is diagnosed 10 to 20% among psychiatric patients. Another reason for this personality disorder gaining special attention with respect to other psychiatric disorders is the high mortality rate, as these individuals have increased inclination towards self- damaging behaviors including suicide and self-mutilation. These patients experience intense anxiety, they are often chronic worriers and fearful of being abandoned by their loved ones, ruminative, and expect the worst. Research has revealed significant gender differences in individuals with BPD as is predominantly being diagnosed in females i.e. up to 75%.

Three Core Features of Borderline Personality Disorder
There is a pervasive pattern of all symptoms characteristic of borderline personality disorder as it is a personality disorder. The core features of borderline personality disorder are clustered around impulsivity, instability in identity interpersonal relationships and unexpected changes in mood. Symptoms falling under these core constructs usually began to surface by early adulthood and are observable in a variety of contexts.

Following are the symptoms of borderline personality disorder that fall under these three main core features:
Drastic and quick changes in attitudes and feelings toward other people such that they might be idealizing someone for a particular time and then started to devalue them or regarding them as incapable of to be with them.
They are overly sensitive to small signs of emotions in others.
Lack of clear and coherent sense of self and experience major swings in such basic aspects of identity as their values, loyalties, and career choices.
They experience chronic feelings of emptiness and cannot bear to be alone.
They have fears of abandonment or being neglected by significant others for which they often to do frantic efforts to avoid it. This fear of impending separation can result in marked changes in behavior, mood, and thoughts.
Impulsivity may also be manifested in self-damaging behavior like gambling, reckless spending, multiple relationship shifts, indiscriminate sexual activity, and the use of drugs at an early age.
Intense episodes of anger expressed towards others and uncontrollable efforts to control it when not being able to cope with the situations effectively which may, in turn, result in damaging their relationships.
Multiple attempts of non-suicidal self-injury and suicidal behavior are particularly common in BPD ranging from slicing their legs with a razor blade or burn their arms with cigarettes to gestures or threats of committing suicide.

Factors responsible for Borderline Personality Disorder

Many different risk factors may lead to the development of borderline personality disorder. These include the genetic factors, certain neurological factors that account for the brain anatomy disturbances or hyperfunctioning or hyperfunctioning of certain regions. Thirdly the factor that leads to this is the combination of biological and environmental factors. Following is the brief description of these factors:

Genetic Factors
Genes account for more than 60%of the variance in the development of this disorder. First-degree relatives of patients with BPD have high rates of disorders related to impulsivity, such as substance abuse and antisocial personality disorder. Also, a personality disorder may develop if certain traits characteristic of the disorder is inherited like anxiousness, impulsive anger is inherited that further make the individual vulnerable to it.
Neurological factors
People with borderline personality disorder have problems regulating their emotions. This emotional dysregulation is caused by lower serotonin functioning. Also the brain region, the amygdala, involved in emotional reactivity and activity has been found to have heightened activity levels in people with BPD. Another region that plays a significant role in controlling impulsiveness is the prefrontal cortex. Studies have shown that these individuals have low levels of activity and structural changes in the prefrontal cortex. The connectivity between the amygdala and prefrontal cortex is also disrupted that accounts for the impulsive features of BPD i.e. non-suicidal self-injury and suicidal threats and gestures.
Social Factors
Two important factors that come under the heading of social factor are the:

People with BPD are much more likely to have a history of parental separation, verbal abuse, and emotional abuse during childhood. Also, such abuse is more likely to be prevalent in an individual with borderline personality disorders as compared to other personality disorders.

The interplay of biological and environmental factors
The following cycle explains the interaction of biological and social or environmental in the development of borderline personality disorder.

The above-illustrated example shows that the emotionally dysregulated individual makes enormous demands on his or her family. The annoyed parents ignore or even punish these outbursts, which leads the individual to suppress his or her emotions. The suppressed emotions build up to an explosion, which then gets the attention of the parents. Thus, the parents end up reinforcing the very behaviors (such as self-harming behavior of using a knife for cuts) that they find aversive. Thus a constant back-and-forth between dysregulation and invalidation in the model explains how through the biological vulnerability and environmental factors individuals are susceptible to the development of borderline personality disorder.

Two Main Complications
Patients show their interpersonal problems in the therapeutic relationship as much as they show in other relations.
Patients alternately idealize and belittle the therapist, they often demand special attention and consideration one moment, for example, asking for therapy sessions at odd hours and countless phone calls during periods of particular crisis and refusing to keep appointments the next moment.
Is BPD curable??
A borderline personality disorder is a complicated mental illness. Like other personality disorder, its treatment requires the integration of various psychosocial interventions. The following are the treatment modules frequently being employed by the psychologist for treating BPD.

Schema Focused Therapy (SFT)
In schema-focused therapy, the therapist and the patient work to identify the maladaptive assumptions (schema) that he or she holds about relationships from his or her early experiences. It is assumed that the person also has a schema for healthy relationships and the therapy aimed at increasing the use of these healthy schemas, rather than automatic behaviors reflecting the problematic relationship schema.
Four Phased Cognitive Behavior Therapy
In the first stage, dangerously impulsive behaviors are addressed, with the goal of promoting greater control.
In the second stage, the focus is on learning to modulate extreme emotionality. This phase might involve coaching to help a person learn to tolerate emotional distress.
In the third stage, the focus is directed towards improving relationships and self-esteem.
The fourth stage to promote connectedness and happiness. Throughout the therapy, an individual learns more effective and socially acceptable ways of handling their day-to-day problem rather than over-reacting towards these problems.
Dialectical Behavior Therapy
One of the most recommended therapies for borderline personality disorder is dialectical behavior therapy (DBT). Many mental health experts believe that weekly therapy sessions involving education about the disorder, social support, and emotional skills training along with medication can treat most of the cases.
Drug Treatment for Borderline Personality Disorder
Drugs are required for symptomatic management of Borderline Personality Disorder. The mainstay of treatment is psychological. To manage aggression and impulsivity, there is a need to prescribe a low dose of antipsychotics or mood stabilizers. Ths use of antidepressants is when there is co-morbid depression. These patients are prone to use drugs of abuse. If this is the case, medicine will be according to the guidelines of addiction management.
Case study
A 20 years old girl, unmarried, studied till intermediate belonged to an urban background, came to a psychiatric hospital with her mother with the complaints of history of repeated self-mutilating behaviors, anger outburst towards family members, feeling of being emptiness, the decline in interest in all activities. She was fairly well as reported by the mother three years back. The onset of illness was after her Matriculation exams. Symptoms started with self-harming behaviors of cutting her own hands by the blade, hanging herself and taking sedatives on minor disputes with family or quarreling with friends. She has a demanding nature towards her parents and was reckless with occasional instances of anger. She had difficulty to control her anger & mood shifts were also prevalent. The quality of the relationship with her friends & family was not good. She had a history of multiple affairs and also she had run away from home several times & lived with his boyfriend’s house. She had always been occupied with feelings of insecurity and has a fear of being neglected by her significant others due to which she did avoid much social interaction as leaving those events made her lonelier. She tried to portray a very strong picture of her in front of others as she was very happy. Her family environment was described as very chaotic, hostile and distressful. Family rules were harsh, rigid and inconsistent. She was a smoker and did have reported the occasional use of drug ice. Also, the mother reported that she did have a blaming attitude towards her and think of her as not being a good caregiver.

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