Borderline Disorder and Psychotherapy

 

Borderline Personality Disorder

Dr Jonathan Haverkampf

 

Borderline Personality Disorder (BPD), sometimes also referred to as emotionally unstable personality disorder, can be seen quite often in psychiatric settings, but it is also quite common outside. Individuals suffering from BPD usually experience emotional impulsivity, periodic feelings of an inner ‘void’, a need to compartmentalize people in ‘good’ and ‘bad’ with little in between, existential fears in relationships and a tendency towards self-harm. Often they have a sequence of unstable relationships and fragmented CVs. The term ‘personality disorder’ is insofar correct as people with BPD have communication patterns with their environment which leads to unstable relationships and considerable suffering.

There is little from the biological corner to explain BPD. Most sensible explanations have come from the realms of psychology, psychoanalysis in particular. The term for the condition is derived from a psychoanalytic perspective in which this condition is seen as being on the ‘border’ between neurosis and psychosis. This sounds like an exact localization, but really allows for a spectrum of manifestations because there is little clear definition where neurosis ends and psychosis begins. The terms ‘neurosis’ and ‘psychosis’ are anyway problematic, because hardware and software in the brain are tightly interconnected and influencing each other.

Since the suffering in BPD is caused by a fear of disconnecting from oneself and others I would describe it in terms of this fear itself. BPD can lead to lifelong suffering if it is not treated. It is associated with unstable relationships, unstable emotions and an unstable sense of self. Interestingly, this instability is caused by the fear that they may be unstable and lost easily. The problem with BPD is that the fear leads patients to behave in ways that put a strain on relationships, even though strong relationships can help someone with BPD considerably.

Substance abuse, depression, and eating disorders are commonly associated with BPD. [1] Up to one in ten patients die by suicide [2], illustrating the individual suffering that comes along with it and the severity of this condition.

BPD can manifest itself in a number of characteristic way. Symptoms commonly include emotional instability and an unstable and often fragile sense of self. Quite characteristic is also the phenomenon of ‘splitting’, in which people and situations are “black or white”, “bad or good”, with nothing in between. There are many theories for this essential feature of the borderline syndrome. It is obvious that there is a problem with the information processing functions. The indecisiveness of BDP is frequently seen as manipulation, but it is really an obvious deficit in BPD. It is largely irrelevant how much of this information processing deficit can be attributed to biology and how much to psychology. Since large-scale neurodegenerative processes are not part of BPD and the brain remains in a state of high plasticity for an entire lifetime, what counts is that psychotherapy has shown to be effective. All the effective methods focus on how patients communicate with themselves, which then also translates into better communication patterns and more fulfilling interactions with the outside world. The objective of therapy is to build and strengthen this bridge between self and others.

The tendency towards self-harming can in the more severe cases mean cutting oneself with a razor-blade. Most patients describe this as allowing them to feel themselves again. The impulsivity is often associated with fears of losing an important relationship. This may not be apparent to other people, and the patient’s subjective appraisal of the situation may be very different because of different mode of processing information. Unfortunately, the fears of abandonment often lead to strained relationships in the sense of a self-fulfilling prophecy, which just reinforces the patient’s deep-seated fears about the strength and resilience of relationships in general. This profound fear of loss can also lead to the collapse of a therapy if the existential dilemma the patient faces cannot be reflected on.

At the core of BPD is an unstable sense of the self, a mistrust towards oneself. The reason maybe traumata, in which emotions and thoughts have been experienced, that can no longer be integrated in one’s personality and sense of self (which is related to the sense of the story of one’s life).  Underlining this are the dissociation and depersonalization which often occur in more pronounced episodes of BPD. Self-medication or self-harming with drugs is not uncommon, when the emotions and thoughts become directed against the own person, and thus one’s sense of self.

The diagnosis is made by clinical observation, and in some cases by ruling out other disorders that may be present. Biologically the frontolimbic network of neurons seems to be involved [3]. BPD may be at least partially inheritable.

Psychological and social factors play a significant role, as may traumatic experiences in one’s life history. Here it is important to remember that the effect of a trauma can be very different among people and is determined by individual perceptions and existing coping mechanisms. The same objective events can lead to very different emotional and cognitive effects in people, and also to very different mental conditions in the long-run, if at all.

The emotional instability and impulsiveness is associated with a pronounced sensitivity in relationships. People with BPD feel emotions more easily and more deeply.[4][5] It also seems that they experience the emotions for longer and it requires more time to return back to the baseline. Individuals with BPD can be very joyful and loving, while at other times reacting very distressed, impulsive and seemingly aggressive at others. The more intense reactions to rejection, criticism and perceived failure often seems to be based on fear or anxiety.

Borderline Disorder arises from a substantial inner stability and a loss of direction, which often manifests in the sense of ‘void’. Repeatedly existential fears are triggered that lead to great anxiety and emotional outpourings. However, the term is largely a misnomer. We are not really dealing with a border ‘line’ but with a spectrum. Appropriate communication can help fill the void. Exploring the deeper issues, the patient’s interests and values helps to rediscover stability. Again, these are concepts that remain relatively stable and that also point to activities that can mean greater happiness and fulfillment. It does not strengthen the need to see everything as ‘black’ and white’, rather it does the opposite. By given people a greater sense of what is stable in them, the need to partition people and objects into one of two categories is reduced, along with the existential anxiety that actually causes it.

An important element in therapy is thus to help the patient rebuild and strengthen his or her identity. This means identifying values, interests and aspirations the patient really feels strongly about. Especially looking at more basic values can be helpful because they are very stable under normal circumstances and give the patient a sense there are stable elements in the core of the self.

Many patients with borderline syndrome have traumata in their past, although it is important to remember that the effect of trauma is always subjective. Traumata are especially damaging when they strike at one’s fundamental values. They can do so, if one’s values depend more on external messages. If I see my values as socially programmed, society can change them, which throws the whole edifice into great uncertainty. Thus the route back is not to turn the focus away from inner processes, but to focus on them. This can cause resistance and aggressiveness, especially in the countertransference, but it is here where a lot of fruitful work can be done.

Everyone has fundamental values and interests. Some values might be directly encoded, but to a large degree we are only born with the rudimentary communication patterns that help us work out our values. Strong ruptures in communication patterns can damage one’s value system. To heal the damage, it is necessary to focus on learning improved communication patterns with oneself and others, and this is what therapy is all about.

 

 

 

© 2012, 2016 Dr Christian Jonathan Haverkampf. All rights reserved.

jonathanhaverkampf@gmail.com

Dublin, Ireland

Websites on Psychotherapy, Counselling and Communication Coaching: www.jonathanhaverkampf.com; www.jonathan-haverkampf.com; www.jonathanhaverkampf.ie; www.wordnets.com

This paper is solely a basis for academic discussion and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition.

 

 

 

 

 

 

References

 

[1] “Borderline Personality Disorder”.NIMH.

[2] Maj, Mario (2005). Personality disorders. Chichester: J. Wiley & Sons. p. 126. ISBN 9780470090367.

[3] Leichsenring, F; Leibing, E; Kruse, J; New, AS; Leweke, F (1 January 2011). “Borderline personality disorder.”. Lancet (London, England). 377 (9759): 74–84. doi:10.1016/s0140-6736(10)61422-5. PMID 21195251.

[4] Manning, Shari (2011). Loving Someone with Borderline Personality Disorder. The Guilford Press. ISBN 978-1-59385-607-6, p.36.

[5] Linehan, Marsha (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. ISBN 0-89862-183-6, p.43.