Borderline Personality Disorder  
by Stuart Sorensen - RMN

Borderline Personality Disorder (BP) is a distinct disorder in it's own right. It is not, as many suppose, a 'diagnosis of degree'. To put it another way someone with a diagnosis of BP is not 'half a psychopath', nor is it valid to differentiate between the 'borderline' personality disorder and the 'full-blown'.

In part the confusion over the definition of BP is a semantic one. The term borderline has associations with 'halfway' measures and so it is natural to assume that borderline personality disorder means half a personality disorder.

Actually the term refers to the now outdated but once widely accepted notion that sufferers exist on the borderline between psychosis and neurosis (Heller L. M. 1991). It is the BP's propensity to exhibit both neurosis and pseudopsychosis which is the chief diagnostic paradigm.

Within this paradigm a number of clear diagnostic features are evident. The American diagnostic manual, DSM-IV, (American Psychiatric Association 1994) lists nine discrete features and requires five of these to be present over time before a diagnosis of BP can be made. The nine features (reproduced in brief) are as follows:

1 Frantic efforts to avoid real or imagined abandonment.
2 A pattern of unstable and intense personal relationships.
3 Identity disturbance
4 Impulsivity in at least two areas that are potentially self damaging
5 Recurrent suicidal behaviour, gestures, threats or self-mutilating behaviour.
6 Affective instability due to a marked reactivity of mood.
7 Chronic feelings of emptiness.
8 Inappropriate, intense anger.
9 Transient, stress related paranoid ideation or severe dissociative symptoms.

The European version, ICD-10 (WHO - 1992) is largely in agreement with these criteria although less comprehensive in its' description of BP.

Common features of Borderline Personality Disorder

Borderlines tend to experience chronic emotional lability and employ a range of endorphin releasing behaviours to compensate for their marked dysphoria. 

Self harm

One of the major features of Borderline Behaviour is self-injury. Somewhat surprisingly for most people the act of cutting the flesh results in euphoria via the release of endorphins which not only prevents the sensation of pain but also anaesthetises the BP against their chronic emotional distress. This is a major cause of self-harming behaviour among Borderlines.

Mood swings

Emotional lability is a classic feature of BP. Moods can shift rapidly - even minute to minute - with no obvious reason which the onlooker can understand.

Dysphoria

Possibly due to limbic system malfunction borderlines can experience a steadily intensifying combination of a range of distressing emotions leading to a range of anaesthetising behaviours as noted above.

Psychosis

Progressive dysphoria, along with other stressors can give rise to psychotic or psuedopsychotic symptoms which are generally cognitive in nature (thought disorders) but can also include hallucinations, derealisation and depersonalisation.

Splitting

During development it is normal for children to categorise things as either 'all good' or 'all bad'. It is impossible for them to appreciate the 'grey areas' of life in the same way that adults can. This immature cognitive strategy persists in BPs leading to rapidly changing and diametrically opposed opinions about life events and significant others. 

Co-morbidity

Because of their measurable brain dysfunction borderlines are also at increased risk of depression, anxiety disorders, other personality disorders and a range of behavioural and addictive disorders. The latter are secondary to the practice of self-anaesthetising via impulsive or self-destructive behaviours. They are also prone to eating disorders, possibly as an attempt to assert control over themselves and their moods in much the same way as other eating disorder sufferers can. Bear in mind that eating disorders have also been related to sexual issues in development (Lyttle J. 1986 pp. 334 - 335). Incidentally, despite the psychotic features already outlined there is no correlation between BP and schizophrenia.

Although there is general agreement concerning the diagnostic features of BP its' aetiology and treatment have become the focus of considerable debate over recent years. 

Aetiology

In terms of aetiology the arguments can loosely be divided into the two familiar categories of 'nature' and 'nurture' and each argument has a lot to support it. A review of the relevant literature reveals, not unexpectedly, the traditional demarcation between psychiatry and psychoanalysis - a professional division which we as nurses are fortunate enough to be able to avoid in favour of a more eclectic understanding of the condition.

Regarding the 'nurture' argument statistical research has revealed a number of indicators of borderline development including:

1 "history of extreme frustrations and intense aggression during the first few years of life." (Kernberg O. 1975)
2 A history of 'invalidating environments' (Linehan M. 1993 2)
3 Sexual or physical abuse - particularly before age 15 (Herman et al 1989).

The concept of the invalidating environment is that of a situation fraught with erratic and inappropriate responses from significant others to the private experiences (thoughts, beliefs, emotions) of the developing BP. In addition the rule of thumb in environments such as these is to oversimplify the ease with which problems can be solved, thus apportioning blame to the BP who is criticised for their inability to easily overcome their difficulties. Over time this can result in a chronic and classical 'double bind' scenario.

The significance of physical and sexual abuse in childhood is emphasised by a number of separate studies: (Goldman S.J. et al 1992;Weaver T.L. et al 1993; Stone J. 1990). It should be remembered, however, that a history of Child Sexual Abuse is not a firm diagnostic criteria and there are many cases of BP who do not report such a history. Nevertheless it remains a remarkably common factor in the development of both male and female BPs.

These have led to some very relevant observations concerning the conditions' correlation with Post Traumatic Stress Disorder. Kroll J. (1988) suggested that the brief psychotic or psuedopsychotic interludes experienced by BP sufferers are no different from those of PTSD sufferers. It is also significant that research into PTSD using the Trauma Symptom Inventory (Briere J. 1997) correctly identified 89% of inpatients independently diagnosed as BP. Wether or not PTSD is a major component in the development of BP it is clear that many BPs have significant psychological trauma in their histories.

Of course any discussion on the aetiology of BP would not be complete without consideration of the other side of the argument - the 'nature' theory. Briefly, this area of research focuses upon the genetic or biological component of BP. Teicher et al (1994) identified dysfunction in the limbic system, particularly relating to the hippocampus and amygdala although the research was unclear as to wether this dysfunction was the result of neurological changes secondary to abuse. 

"The Hippocampus .. is essential for the laying down of long term memory. The amygdala, in front of the Hippocampus, is the place where fear is registered and generated." (Carter R. 1998 p.42)

Given the essential functions of these two areas of the brain we can begin to understand the possible neuro-biological origins of certain Borderline traits such as emotional lability, splitting (the tendency to characterise things as 'all good' or 'all bad'), and the condition's dissociative traits. 

It is interesting to note that many researchers have identified serotonergic dysfunction in the brains of BPs. This may have marked implications for the maintenance of mood and also go some way towards explaining the frustration and rage routinely exhibited by sufferers (Siever L.J. 1997).


Equifinality model

The equifinality model postulates that both the 'nature' and 'nurture' paradigms are equally valid. In brief it suggests that a biological vulnerability, perhaps inherited in BPs with a family history of neurological disorder or created as a result of neurological changes secondary to PTSD in childhood is a necessary element of Borderline Personality disorder. The biological sequelae of childhood trauma is an area which we are only just beginning to understand. New studies suggest a wide range of neurobiological changes as a result of childhood sexual abuse (Siever L. J. 1997).

In addition to the biological factor, however it may arise, trauma of one kind or another does appear to be vital. This may be sporadic as is often the case in physical or sexual abuse or more chronic as already noted via the mechanism of Linehan's 'invalidating environment'. 


Treatment

It is no secret that this particular client group can be something of a nightmare when it comes to finding effective therapeutic interventions. The treatment of BP is fraught with difficulty, particularly in an in-patient setting where many borderline behaviours result in discord among the staff or where the demands made upon an individual nurse can become extremely unrealistic.

Treatment of BP falls into two main categories - pharmacology, incorporating a range of medication options and psychotherapeutic techniques ranging from supportive counselling to psychoanalysis. Although many of the treatments available fall firmly outside the remit of the RMN it does no harm for nurses to understand the options available.

Pharmacological treatments include:

SSRIs to combat the deficiencies in serotonin absorption.

Neuroleptics to treat psychotic symptoms as well as dysphoria .

Carbamazepine has been used in the treatment of behavioural and affective problems (Cowdry R.; Gardner D. 1988).

Thyroxin as many BPs have symptoms of hypothyroidism
It has been reported that alprazolam can decrease behavioural control and that amitriptyline increases paranoia, assault and suicide threats (Cowdry R.; Gardner D. 1988).

Psychotherapeutic approaches to Borderline Personality Disorder are dogged with the same problems of compliance as pharmacological approaches are. This is in no small measure due to the difficulty Borderline patients have in forming the stable relationships generally seen as a pre-requisite for therapy.

Nevertheless 'talking cures' are effective in conjunction with medication and it seems that both types of intervention are necessary. If counselling is designed to help people think through their difficulties and learn to take control of and responsibility for their emotions it makes sense to give the brain a fighting chance to work properly at the same time. 

The most effective form of therapy for BPs seems to be 'Dialectic Behaviour Therapy' (Linehan M. 1993 2). This is at first glance a very strange juxtaposition of traditions drawing as it does from 'cognitive behaviour therapy', 'supportive counselling' and 'zen Bhuddism'. The term Dialectic refers to the inherent dichotomy of BPs experience in which everything is polarised into extremes such as rejection/acceptance; good/bad; active; passive and crisis/calm. The term Dialectic refers to the scenario of opposing viewpoints characterised by thesis and antithesis in classical philosophy.

In essence the technique is designed to promote insight and change via skills training, introspection and validation. This in itself is seen as dichotomous as validation and acceptance in the mind of the BP (black and white thinkers) is not conducive to encouragement to change.

The downfall for acute psychiatric wards is that the procedure typically takes 1 - 3 years and requires a consistent approach from two separate therapists who will (in certain circumstances) make themselves available to the BP round the clock. Needless to say this is not a realistic option for ward based RMNs.

However many of the techniques of DBT are extremely valid and can be used in acute. In particular the principles of validation and skills training are very appropriate.

But herein lies the rub. If such an approach is to work it requires firm boundaries and a consistency of approach which is historically very difficult to maintain on acute. This is particularly true in the treatment of BPs who can be adept at eliciting a range of responses from staff via the mechanisms of transference and counter-transference.

What we do have is the opportunity to promote self-acceptance and, in conjunction with medication prescribed by our medical colleagues, the chance to promote a range of skills from problem solving to anger management. It seems that BP is less of a lifestyle choice than many of us, myself included, previously thought. There are very real psychological and biological/organic deficits which can be addressed and treated effectively.


REFERENCES


American Psychiatric Association (1994)
Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition (DSM-IV)

Briere J. (1997)
Psychological Assessment of Adult Posttraumatic States
American Psychological Association
Washington D.C.

Carter R. (1998)
Mapping the Mind
Phoenix
London

Cowdry R.; Gardner D. (1988)
Pharmacotherapy of Borderline Personality Disorder
Archives of General Psychiatry
Vol. 45

Goldman S.J. et al (1992)
Physical and sexual abuse histories among children with borderline personality disorder
American journal of psychiatry
149 (12) 1723-1726

Heller L.M. (1991)
Borderline Personality Disorder: New Management Concepts
http://www.biologicalunhappiness.com/
P. 2

Herman et al (1989)
Childhood trauma in Borderline Personality Disorder
American Journal of Psychiatry
151(2), 277-280

Kernberg O. (1975)
Borderline Conditions and Pathological Narcissism.
Jason Aronson

Kroll J. (1988)
The Challenge of the Borderline Patient
Norton & Company
New York

Linehan M. (1993) 1
Cognitive Behavioural Treatment of Borderline Personality Disorder
Guildford Press
New York

Linehan M. (1993) 2
Skills Training Manual for Treating Borderline Personality Disorder
Guildford Press
New York

Lyttle J. (1986)
Mental Disorder: its care and treatment
Bailliere Tindall
London

Siever L.J. (1997)
The Journal for the California Alliance for the Mentally Ill
Reproduced on the internet by
Mount Sinai School of Medicine
Dept. of Psychiatry
Via
www.mental-health-today.com
Stone J. (1990)
The Fate of Borderline Patients
Guildford
New York

Teicher et al (1994)
Early abuse limbic system dysfunction and borderline personality disorder
In Silk K.R. (Ed)
Biological and Neurobehavioural studies of Borderline Personality Disorder
American Psychiatric Press
Washington D.C.

Weaver T. L. et al (1993)
Early family environments and traumatic experiences associated with borderline personality disorder
Journal of consulting and clinical psychology
61(6) 1068-1075

World Health Organisation (WHO) (1992)
International Classification of Diseases
World Health Organisation
Geneva