Borderline Personality Disorde Essay Research Paper BORDERLINE

Borderline Personality Disorde Essay, Research Paper

BORDERLINE PERSONALITY DISORDER

Copyright 1999 John M Rathbun MD

DEFINITION – a pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsiveness, beginning by early adulthood and present in a variety of contexts

HISTORY:

* this diagnosis has been used over the past 30 years to label patients who get therapists upset.

* BPD has become the most diagnosed and researched personality disorder.

EPIDEMIOLOGY:

* two or three per cent of the general population are affected

* most common personality disorder in clinical settings

* diagnosed in 11% of psychiatric outpatients, 19% of inpatients, and about half of all personality disordered patients

* three times as common in women as in men

* five times more common in first degree relatives of affected persons

ETIOLOGY:

* well over half are victims of physical and/or sexual abuse

* dysfunctional family dynamics are common

* mothers often erratic and depressed

* fathers often absent or have major character problems

* early losses common

* genetic data implicate constitutional factors

DIAGNOSIS:

* typically present with dependent behaviors, seeking nurturance, closeness, and assistance

* within a therapeutic relationship, show escalating need for support

* when frustrated, show rage and devaluation of therapist

* relationships typically unstable, intense, and stormy

* they show extremes of idealization and devaluation

* may become extremely ill and self-destructive in reaction to fear of abandonment

* commonly have other personality disorders, mood disorders, substance dependence, bulimia, and PTSD

DIFFERENTIAL:

* Compared to cyclothymic and bipolar patients, BPD more reactive, angry in reaction to frustration in dependent relationships, with chronic feelings of emptiness

* compared to depressive disorders, BPD more manipulative in their suicidality and have poorer relationships

* compared to psychotic disorders, BPD have brief, reactive psychotic symptoms, not chronic, persistent ones

COURSE:

* typical BPD emerges in adolescence

* BPD especially severe in twenties

* about half improve spontaneously in thirties and forties

* BPD commonly fail in education, employment, and relationships

* suicide claims eight to ten per cent; many more carry scars of self-mutilation

MEDICAL TREATMENT:

* SSRIs and mood stabilizers help impulse control and moodiness

* antipsychotics help ideas of reference and brief psychotic symptoms (newer antipsychotics especially olanzapine)

* benzodiazepines and MAC’s make things worse

PSYCHOTHERAPY:

These are difficult psychotherapy patients. They have a lot of turbulent emotion in relation to the therapist, and they act out in ways that endanger them and irritate the therapist. Therapists are tempted to reject or indulge BPD.

It often takes five or more years of intensive individual psychotherapy to resolve BPD.

The therapist must be consistent and reliable, with excellent boundary management.

These patients routinely induce splitting in treatment teams.

They will not progress in therapy if currently being abused; they may under-report or over-report abuse.

These are not cases for the beginner, and student therapists should have intensive supervision when working with borderlines.

A DYNAMIC FORMULATION:

Ego States Theory was developed to explain why some adults intermittently behave like children. According to Ego States Theory, we all start out life as a collection of unintegrated ego states, such as “Happy baby”, “Hungry baby”, “Scared baby”, “Mad baby”, and “Sleepy baby”. We observe normal infants making abrupt switches between these ego states according to their current circumstances, and there seems to be little continuity of memory from one such ego state to the next. We observe normal parents sponsoring integration of ego states in normal youngsters. The preschooler who falls and hurts himself while playing undergoes a switch from the “Happy child” ego state to the “Scared and painful” ego state, and seems to have no idea that his suffering is a temporary condition. Mother provides reassurance along the following lines: “You’re OK now, even though it hurts; you were happy a few moments ago, and you’ll be happy again in another few minutes!” We can later observe the same child in grade school getting hurt, starting to switch ego states, and then reassuring himself that he’ll feel better soon, thereby maintaining his own ego integration. In adulthood, the fabric of ego integration is usually so tightly woven that it takes a catastrophe to cause dissociation of ego states.

Some children, however, don’t have a “normal” childhood with the support of well-integrated parents. Suppose father is alcoholic: he may come home drunk and rape the little girl, and the next day he may not remember what he did. Mother may be physically or psychologically absent from what’s going on with her daughter, so father is her only source of comfort. The ch

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