Clichéd: “Borderline” — an attempt at enlightenment
Today I will not talk about dissociative identity disorder (DID, syn: multiple personality disorder), but about another mental illness— borderline personality disorder (BPD) or emotional-instable personality disorder, type borderline. Epidemiologically, BPD is a little more common than DID (2–3%) and occurs mainly in younger people, mainly women (but not only!). The clinical picture is complex and difficult to distinguish from DID and post-traumatic stress disorder (PTSD). In addition, other disorders (such as eating disorders, depression, PTSD, addicition disorders, other personality disorders and ADHD) often occur simultaneously, i.e. so-called comorbidities. In order to diagnose BPD, 5 of the following 9 criteria must be fulfilled (personalitydisorder.org.uk):
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance: markedly and persistently unstable self image or sense of self.
- Impulsivity in at least two areas that are potentially self- damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self- mutilating behavior covered in Criterion 5.
- Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior.
- Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
You see — I meet some of these criteria (3,5,6 and 9), which is why I was also diagnosed with BPD. In addition, I have been self-harming since I was 12 years old — which many (wrongly) classify as typical borderline. However, what is totally atypical is that I have had a stable relationship for 10 (!) years and my career aspirations have been very constant. I will explain in a separate post what the differences are to DID and how to tell them apart — it’s really not that easy and there are many overlaps. Classic for borderliners is especially the feeling of emptiness, the tendency to extreme emotions and a pronounced black-and-white thinking, which leads to great inner states of tension (powerlessness, helplessness). They then develop dysfunctional behaviour patterns (self-harm, drugs, alcohol, etc.), which run automatically and allow the patients to deal with these states of tension (dysfunctionally). Dissociative phenomena (splitting off from the self) and disorders of pain perception can also occur. Traumatic experiences (physical, sexual or emotional abuse) are often at the root of the disease.
It is important to mention that the disorder usually begins in early adolescence, it is usually diagnosed later (I was diagnosed at the age of 24), and it has its peak at the age of approx. 27 years. The reason of delayed diagnosis is that a personality disorder must be a “persistent disorder of the personality”. So many things and changes happen during adolescence that it is impossible to tell at this stage whether the symptoms are long-term or temporary. General characteristics of personality disorders are:
- enduring pattern of experience and behaviour
- Pattern is inflexible and deep
- Pattern causes suffering and impairment in areas of social functioning
- Pattern is stable and enduring
- Exclusion of substances or other mental disorders as cause
There is no medication that cures borderline patients — unfortunately! However, depending on the clinical manifestation, certain medications such as antidepressants or sedative drugs are administered. Central to BPD therapy remains psychotherapy and there in particular dialectical-behavioural therapy according to Linehan. Because this is such a big topic and would go beyond the scope of this article, I will write about it another time.
So take me as I am
This may mean you’ll have to be a stronger man
Rest assured that when I start to make you nervous
And I’m going to extremes
Tomorrow I will change
And today won’t mean a thing
Meredith Brooks “Bitch”
A borderline diagnosis is still very stigmatising. Patients are usually accused of being incapable of having relationships, of not being resilient and of being manipulative. I have met many borderline patients and I must say that I cannot agree with this. I met people who have been married for years, have children or are in the process of working. Of course there are other cases that fit the “classic image” of a borderline person — but to draw conclusions from them about all BPD patients is simply wrong and discriminatory. And there is something else I would like to point out here: Not every self-injury automatically means a BPD disorder! Self-harm can also occur in other disorders such as depression, bipolar disorder, autism, antisocial personality disorder, DID or eating disorders (actually, food restriction is also a form of self-harm!). Moreover, self-injury is not only understood as actively inflicting harm on oneself (cutting, pulling out hair, punching walls, etc.), but also as risky, harmful behaviour (e.g. driving too fast) or neglecting oneself — so self-harm has many faces!
The prognosis of the disease is extremely promising, with only 60% meeting the criteria two years after diagnosis and only 20% after 8 years — a huge therapeutic success! (Zanarini 2003/2006, Grilo 2004) I will soon go into more detail about the specific BPD therapy — I could write a doctoral thesis on that alone! I hope to have given you an insight and that you now understand the clinical picture a little better and thus the prejudices (which will also be dealt with in a separate blog) will decrease. See you soon!