Understanding borderline personality disorder

Dr Meesha Haorongbam *

Personality- a seemingly innocent word that we often use in our day to day conversations. We often judge our impression of people based on their personalities. So it comes as no surprise that some beauty pageants even have a subcategory called "Miss/Mrs. Personality". But what exactly is personality? Oxford dictionary defines it as "the combination of characteristics or qualities that form an individual's distinctive character".

From the psychological standpoint, personality can be decomposed into temperament (basic emotions), character (rational concepts about self and interpersonal relations), and psyche (intuitive self awareness and fluid intelligence). Basic functions of personality are to feel, think, and perceive, and to incorporate these into purposeful behaviours.

But when a person has an unhealthy pattern of perceiving, feeling, or thinking, leading to unhealthy behaviours, then the person is said to be suffering from a type of mental illness known as personality disorder. In other words, a personality disorder represents "an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture".

These patterns are usually evident during adolescence and persist into adulthood and the symptoms may range from mild to severe. The worldwide prevalence of personality disorders is 7.8% while its prevalence in India varies from 4%-7% based on different studies. As of this writing, there is no data on the prevalence of personality disorders in Manipur.

Any personality disorder, in fact any mental illness, takes a heavy toll on the person and their loved ones. But no other disorder is as controversial and as misunderstood as borderline personality disorder (BPD). It has been depicted (though wrongly most of the time) in movies such as Welcome to Me, Silver Linings Playbook, The Eternal Sunshine of the Spotless Mind etc.

Famous people such as Angelina Jolie, Megan Fox and others have also been presumed to have BPD. The myths and stigma surrounding an illness that affects 1.4% of the population ought to be banished and replaced by awareness and understanding.

BPD is one of the two Emotionally Unstable Personality Disorders (EUPD); the other being Impulsive Personality Disorder (IPD). It is seen more in females (75%) and in younger people, suggesting a natural tendency toward maturation and remission. BPD is characterised by a tendency to act impulsively without consideration of the consequences, together with emotional instability.

Common features of BPD are:

1. Outbursts of intense anger especially when impulsive acts are criticized or thwarted.
2. Intense fear of abandonment and excessive efforts to avoid abandonment such as cutting off communication with someone in anticipation of being abandoned.
3. Recurrent threats or acts of self harm
4. Chronic feelings of emptiness
5. Unstable and capricious moods
6. Uncertainty about self image, aims and internal preferences
7. Unstable and intense interpersonal relationships, alternating between idealization and devaluation, which often leads to emotional crises.
8. Impulsivity in self-damaging areas like reckless spending, sexual activities, substance abuse, binge eating, reckless driving, gambling etc
9. Tendency to undermine self when close to realizing a goal
10. Feeling more secure with nonhuman objects (e.g. pets) than in interpersonal relationships due to irrational fear of other people's intentions

Not everyone will BPD experience all of the symptoms. Some experience just few symptoms while others experience many.

CAUSE

Personality develops through the interaction of hereditary dispositions and environmental influences. The same holds true for personality disorders. Numerous studies have pointed to an interaction between childhood trauma, biological vulnerabilities (mostly in the emotional domain), and a series of triggering events as the cause of BPD. Triggers can be external or internal and can be seemingly ordinary events.

They vary from person to person, but there are some that are shared in BPD. The most common are interpersonal relationship triggers which can be real or perceived rejection of any kind, loss of job, and end of relationship. In people with history of traumatic event(s), a memory, location or image of a past traumatic experience can bring about intense emotions which may act as a trigger.

Triggers need to be recognised and understood as it helps in managing BPD. Episodes are highly specific to individuals. It can range from becoming withdrawn and avoidant to paranoid thoughts of everyone hating them to emotional highs and bursts of euphoria.

RISK FACTORS: These factors merely increase a person's chance of developing BPD. They do not imply that those with these risk factors WILL have BPD. Likewise, even those without these risk factors may develop BPD.

1. Family history- People who have a family member of BPD are at a higher risk for developing this illness.

2. Brain imaging- Studies show that people with BPD have structural and functional changes in the areas of the brain that control impulses and emotional regulation. Whether these are the cause or effect of this disorder is not yet fully understood.

3. Environmental factors- Traumatic life events such as abuse, abandonment, neglect, bullying, exposure to invalidating relationships etc.

COMPLICATIONS

BPD can create havoc in many areas of one's life. Frequent job changes or losses, interrupted education, entanglement in legal issues, marital stress or divorce, unplanned pregnancies and motor vehicle accidents due to risky behaviour, and broken marriages are just few of the effects of BPD.

MYTHS & STIGMA

There are still numerous misconceptions surrounding BPD, even among healthcare professionals. This generally stem from lack of awareness. The fact that this disorder happens in the context of relationships which negatively affects their loved ones may also partly be blamed for the stigma around BPD.

Many people still believe that those with BPD are manipulative or dangerous though in reality they're just struggling with their sense of self and their relationships. They are often labelled as "clingy" or "needy" or "desperate" which usually stems from their pervasive fear of being abandoned or their fear that they aren't good enough for anyone.

Their intense emotion and tendency to view everything and everyone in black and white may make them come across as hot and cold. Such misconceptions prevent people from reaching out and cultivate isolation and resentment, and can instigate further impulsive actions. This puts them at an increased risk for depression, substance dependence, eating disorder, and post traumatic stress disorder. There may also be premature death or physical handicaps from suicide and suicidal gestures and self-injurious behaviour.

COURSE

The illness has a variable course. It most commonly follows a pattern of chronic instability in early adulthood, with episodes of serious mood and impulse dyscontrol. The impairments gradually wane with advancing age.

In the fourth or fifth decades, these individuals tend to attain greater stability in their relationships and functioning. Thus it is not a lifelong diagnosis. Numerous studies show a remission rate of 35% after two years and 99% after 16 years.

TREATMENT

Not long ago, BPD was believed to be an untreatable illness. Its very existence was even doubted by psychologists and psychiatrists. But all that has changed now. Many people with BPD are untreated, but not because they're unwilling. It's because this mental illness isn't treated like many others. Psychotherapy is the main treatment modality.

Psychotherapy is mostly aimed at controlling intense emotions, reducing self destructive behaviours, and improving interpersonal relationships. Currently there is no approved drug(s) for BPD but drugs that target their co-occurring disorders such as depression, anxiety, and eating disorders, are given. Hospitalisation may be required especially when there are self-harming or suicidal thoughts and/or behaviours.

Recovery takes a long time but treatment can improve one's ability to function and feel better about themself. Many factors affect the length of time it takes for symptoms to improve, so it is important for them and their loved ones to be patient and to receive appropriate support during treatment.

WHAT CAN BE DONE IF YOU HAVE A LOVED ONE WITH BPD?

The feelings and behaviours associated with BPD are very difficult to live with and cause intolerable strain on their loved ones too. "Walking on eggshells" is a phrase often used to describe what it's like living with someone with BPD. Relatives and friends may unintentionally act in ways that can worsen their loved one's symptoms.

Here's what you may do if you know someone with BPD:
1. Educate yourself about the disorder so that you can understand what your loved one is experiencing.
2. Seek information only from reliable sources and be wary of stereotypes you may come across.
3. Offer support, understanding, and encouragement.
4. Encourage the person to seek treatment.
5. You may seek help for yourself should you feel the need.

CONCLUSION

BPD is a clinical diagnosis. It is not a judgment about one's character and behaviour though the behaviour does cause pain to others. BPD doesn't predispose traits such as abusiveness or manipulativeness. It just makes them more vulnerable and fearful. Remember, the best thing you can do if you have BPD is to seek treatment.

You owe it to yourself, to your loved ones, and to society, to take the best possible care of yourself and live a contented life as a useful contributor to society. Removing the veil of stigma around the disorder will surely help and that all starts with some understanding.

"People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement"
- Dr. Marsha Linehan, psychologist who developed Dialectical Behaviour Therapy, the main treatment method for Borderline Personality