Borderline Personality Disorder

Borderline Personality Disorder

While borderline personality disorder (BPD) has a history of sorts, it seems that we are hearing more about it as of late.  But what is it?  Is it a personality disorder, or is it an anxiety disorder?  Setting aside the medical community's definition and its classification in the Diagnostic and Statistical Manual of Mental Disorders - 5 (DSM5), it seems to me that it is largely based in moods, anxiety and inability to connect properly with others.  I am certainly not looking to move mountains and change its definition or classification; I want to first explore what BPD is, and then consider available treatments.  Finally, I wonder, are there success stories out there?

What is BPD?

First off, BPD is not psychosis, but sometimes it might look like psychosis.  What I mean is when a person with BPD is contemplating suicide, or their irrational thoughts run away from them, the reaction can very much look like a psychotic break.  In reality, this person is genuinely struggling with how to cope, and like someone with anxiety having a panic attack, the feelings are very real and very rational in the moment. 

Let's take a step back for a moment, when an individual with BPD is struggling to "keep it together" in the moment, their fight or flight mechanism is out of whack - the body's alarm system - the amygdala - is screeching at full blast to the emotional processing centre of the brain - the thalamus - that there is a problem, and fight, flight, or even freeze needs to happen to protect the self.  This in turn prevents the rational part of the brain to sort through it all and make a rational decision of next actions.  Think of it as a terrorist attack on the body which hijacks rational thinking; what do you think happens next?  The body reacts to survive.  But when this entire system is broken, and the body is constantly being hijacked, the body is fooled into sounding the alarm, even when it doesn't really need to.  So to the untrained eye, it looks like a full blown mental breakdown.

I know, that doesn't really explain what BPD is, but I think this background is important to get a better understanding of what BPD is.  It is indeed a serious mental illness that includes mood instability, difficulty with interpersonal relationships, issues of self image and at times erratic behaviors as a result of these instabilities.  The borderline part came from the initial belief that its characteristics were thought to be at the border of psychosis.  Individuals with BPD have difficulties with emotion regulation, which is why we see the erratic behaviors, self harm and suicide attempts.  BPD is typically first seen in older adolescents and young adults - it is more common in females than males.

Here's a link to Marsha Linehan's story; the psychologist who developed dialectical behavior therapy (DBT) to treat BPD.  She too struggles with BPD, which is what makes it such an interesting story.

What does BPD look like?

A person who struggles with BPD experiences intense bouts of anger, depression, or anxiety that may last only a few hours or a few days.  Additionally, there may be impulsive aggression, self-injury, suicide attempts and drug and/or alcohol abuse.  These are typically fuelled by distortions in thoughts and sense of self which make it difficult for the person to plan long-term with respect to goals, career plans, friendships, identity and jobs. 

One of the most common fears experienced by individuals with BPD is that of isolation; the individual will at all costs avoid being alone.   For example, let's say that Susan has plans with her boyfriend to go out to dinner and a movie, but her boyfriend calls her up within hours of their date to tell her that he has to cancel the date because his best friend was involved in a serious car accident.  He tells her that he is sorry, but he needs to be there for his friend and his friend's family.  As Susan takes in this information, her emotional brain takes over and leads her to believe that her boyfriend is abandoning her and he doesn't like her anymore and would rather be with other people.  She might react with an emotional outburst containing a few nasty words.  She might then try to reach out to her other friends, for support, and if she is really out of control with her thoughts, she may even self-harm or attempt suicide.  This is not to say that everyone with BPD will react this way, but it is not completely uncommon - this is just how strong the fear of being alone manifests.  In essence, these unstable patterns in social relationships develop into attachments that are unstable, because they are like a severe storm - they shift from idealization to devaluation in a blink of an eye.

What Causes BPD?

That's sort of unclear.  There is a general consensus that BPD has roots in factors of environment and genetics.  That being said, it is more likely to present in people who have a close biological relative with BPD.  The literature tells us that many individuals with BPD experienced some form of abuse, neglect or separation as young children which has negative affects on their ability to trust others, and form secure attachments. 

From a neuroscience perspective brain mechanisms that underlie impulsivity, mood instability, aggression, anger and negative emotion typically seen in BPD.  The science tells us that people predisposed to impulsive aggression have impaired regulation of the neural circuits that regulate emotions - there's that amygdala again!

Treatment

It is believed that neurotransmitters serotonin, norepinephrine, and acetycholine are the chemical messengers that play a vital role in the regulation of emotions.  Medications enhance serotonin function and may improve the emotional symptoms in BPD.  Mood-stabilizing medications can help people with BPD who experience mood swings.  Additionally, behavioral interventions such as DBT (mentioned above) and cognitive behavior therapy have reasonably demonstrated therapeutic effects to help restore greater normative functioning.

Jade, provides some great tips on how to seek help for those who struggle with BPD.  Her blog contains great information on what to look for in a practitioner, and a health care team.  She recognizes that BPD is both a psychological and medical disorder, and with proper care and treatment she made some significant gains in her life with BPD.

No doubt, BPD is frightening, particularly for the one experiencing its insidious symptoms.  Treatment is not always easy to find, and it can certainly feel isolating - the very thing these individuals fear - but there are treatments; good, evidence-based and effective treatments.

Mental Illness Stigma

There is no doubt in my mind that we have not even begun to scratch the surface in talking about mental illness.  Scanning the news demonstrates this to me everyday with countless stories of the impact of mental illness in the workplace, at home and even for first responders and the military.  Let's not forget the tragic number of completed suicides.  Despite the number of social campaigns that serve to remove the stigma of mental illness, such as Bell Canada's Let's Talk, or celebrities sharing their personal stories, it doesn't seem to be enough.  There still seems to be a considerable number of people who perpetuate the stigma, or on the opposite end, fear it.  Is there a better way to break down the stigma associated with mental illness?

A quick Google search of key terms: mental illness and stigma produces an exhaustive list that ranges from informative to flat out drivel.  How is one supposed to differentiate from what is research and evidence-based to what is meaningless and unhelpful?  Additionally, if we take a deeper look at the content of the search results, we will likely find that cultural and socioeconomic content is lacking; instead the focus seems to be on white women with anxiety and white men with depression.  This bring forth another concern - that the focus on mental illness seems to be isolated to mood related disorders.  The truth is mental illness affects everyone, and it encompasses much more than depression and anxiety - what about psychosis, borderline personality disorder, bipolar disorder - should they not get a seat at the table too?

Don't misunderstand me, anxiety, depression, and even posttraumatic stress disorder (PTSD) are certainly more prevalent in our society, but the definition of mental illness doesn't stop there.  Indulge me for a moment, let's talk about those celebrities that have spoken up about the effects of mental illness on their lives - first and foremost, telling their story was, and continues to be, brave - it takes a lot of courage to talk about something that is so deeply personal.  If hearing someone speak about the challenges of mental illness helps just one person, than in my opinion, it has been effective - however, at what point does all this talking translate into action?  By this I mean, when will the existing barriers that restrict access to mental health services come down?  In the province of Ontario, anyone looking for mental health services faces long waiting lists upwards of 3 to 6 months, unless they have insurance benefits and/or are willing to pay for services .  Again, the message that social awareness campaigns carry is that mental illness affects everyone - so why can't everyone get access in a timely manner? 

Anxiety: Physical, mental, or both?

What does mental illness look like?  Is it physical or just psychological?  Most would likely agree that it is both, and others might believe it is only psychological.  Certainly, symptoms of anxiety can include physical symptoms such as loss of appetite, nausea, sweating, and/or heart palpitations.  On the other hand, the psychological symptoms for anxiety might include ruminating thoughts, excessive worry, and/or unexplained fear.  But what if one causes the other?  Consider the following:

Adolescents with a long history of asthma are more likely to develop an affective disorder, namely anxiety and/or depression (Hommel et al., 2002).  Through the use of relaxation techniques and biofeedback, asthmatics with panic disorder have demonstrated improvements physiologically with decreased heart rate, increased pulmonary function, expiratory flow rate and stress management (Hommel et al, 2002).  Psychologically, with cognitive behavior therapy (CBT) and cognitive reframing skills; and social improvements by re-engaging in sociable and pleasurable activities (Hommel et al., 2002).

Certainly, evidence-based psychological treatments can improve psychological functioning for ailments such as anxiety and depression - are they enough?  Or does one fare better with antidepressant medication alongside psychological treatments?

Stay tuned, there is a lot to talk about when it comes to anxiety!

Reference:  Hommel, K. A., Chaney, J. M., Wagner, J. L. & McLaughlin, M. S.  (2002). Asthma-specific quality of life in older adolescents and young adults with long-standing asthma:  The role of anxiety and depression. Journal of Clinical Psychology in Medical Settings, 9(3), 185-192.  doi:10.1023/A:1016066709714