Q. My mother is 63 years old, and has previously been diagnosed with OCD, panic disorder, agoraphobia and major depression. These were all treated as separate disorders. There is suspected incest, although that has not been addressed. She has been hospitalized 4 times since the age of 35 and is currently on high levels of Prozac, Serzone and I believe Xanax. She is fairly functional at this time (suffering mostly from bouts of severe depression) and currently does not display any signs of the OCD, panic disorder or agoraphobia.

However, in researching personality disorders myself, I find that she meets an overwhelming number of criteria of BPD -- with two notable exceptions. To my knowledge, she has not been suicidal, and she has not exhibited self-mutilation per se. However, she has had a long history of physical "illnesses" such as migraines, stomach disorders, joint and foot pain, goiter, eye problems, urinary tract infections, etc....all of which seem to "disappear" when further diagnostic steps are recommended (with the exception of the goiter, which was surgically removed). In addition, my mother is very accident-prone -- something which I originally attributed to her heavy medication and drowsiness. Large bruises will mysteriously appear, and she has had numerous 'accidents' such as falls and sprains (particularly before an important event, like a vacation or my father going away on business). She also tends to have minor 'mishaps' in public, such as spilling things on herself. Could this in some way be related to self-mutilation?

As for suicidal tendencies, there are none that I know of -- even during her deepest depressive states. Is it possible that she has thought about it but not expressed it? My understanding is that this is one of the more common traits of BPD, of which she shares: narcissism, inappropriate/intense outbursts of anger (esp. when someone is upset or confronts her about something), anxiety (esp. relating to being alone), idealization/devaluation (people are either good or terrible, and it seems to change weekly), low self-image, impulsivity (in the form of buying things she or others do not need or want, just for the sake of buying them), and what I would describe as 'emptiness' -- lack of interest in pursuing hobbies, working, housekeeping, cooking, or any other activity save interacting superficially with my father, select family and church members (primarily those who have not recently found disfavor), and her two cats.

Any thoughts you might have on this would be greatly appreciated. More than anything else, I want to better understand her behavior so that I can learn healthier ways of reacting to it.

A. Good questions, and they deserve an answer. First, you only need five of the symptoms listed in the DSM-IV to have BPD. Your mother makes this. Whether she has a different type of BPD is an open question. Self-injury is one symptom, but not a necessary one for BPD. Suicidality may also exist (it usually does). It is possible that your mother is just not talking about it, or she really may not have it. This would be an unusual case, but possible.

I have seen no data that discussing the past incest or abuse changes the illness. Whether abuse cause BPD or not is an open question to some, but irrelevant. Once it happens, you cannot reverse the damage. So, you fix as best you can what is broken. If your mother still gets depressed, it may be worth trying something else, or seeing about higher dosages of Prozac. Discuss it with her psychiatrist.