Borderline Personality Disorder

Clinical Description

In trying to understand Borderline Personality Disorder, one may wonder what is the "border" to which the name of the disorder refers. Historically, and from a primarily psychoanalytic perspective, people with the disorder were theorized to be on the bound-ary—the borderline—between neurosis and psychosis, reflecting the severe nature of the syndrome (Stern, 1938/1986). Borderline Personality Disorder has also been referred to as borderline personality organization (Kernberg, 1975), pseudo-neurotic psychosis, and pseudo-neurotic schizophrenia (Hoch, Cattell, Strahl, & Penness, 1962), suggesting that underneath the overt neurotic-like symptoms was a much more profound thought disturbance. The terms also implied that people with the disorder often have the same profound and deleterious effects on the family as a blatantly psychotic person. In the original DSM (American Psychiatric Association, 1952), the concept of borderline psychopathology was officially named the "emotionally unstable personality," which, in our estimation, is a more accurate description of the core feature of the psychopathology (and is free of the psychoanalytic connotations) than the current name Borderline Personality Disorder. In a sense, it is ironic that the name of the disorder is as unstable as the people who suffer from it.

Borderline Personality Disorder is notable for extreme instability in interpersonal relationships, self-image, behaviors, and emotions. Sufferers are also extremely impulsive, which usually results in high risk, dangerous, and self-destructive behaviors, such as substance abuse, sexual promiscuity, reckless driving, compulsive spending, shoplifting, gambling, eating sprees, self-mutilation (e.g., cutting on the self but without the intent of killing oneself) and suicidal threats and behaviors (often with a history of multiple suicide attempts; Widiger & Trull, 1992). The dangerous and chronic self-mutilating nature of the borderline pathology was demonstrated by one of our patients, a 77-year-old woman, who blithely reported at intake that she had "tried to kill herself 76 times in the past 5 years"

and wanted help to "get the job done right." She further reported a chronic history of parasuicidal and self-mutilating behaviors since her teen years, having had over 30 psychiatric hospitalizations and been treated by numerous outpatient clinicians, none of which were perceived by her as helpful.

People with Borderline Personality Disorder often feel chronically bored or empty and are perceived by others as manipulative, mercurial, demanding, and exasperating. They have a poorly defined or unclear sense of self and have the perception that they "do not know who they are" with concomitant uncertainty about their values, goals, loyalties, and career aspirations. There is little sense of meaning in life. Due to an often intense emotional dysregulation, their moods shift rapidly. It is common for the borderline individual to be angry, rageful, and hostile. They tend to rely on splitting as a defense mechanism, regarding themselves, the world, and others in black-or-white terms (e.g., "all good" or "all bad") and they can shift their perspective with alarming alacrity. This cognitive tendency toward dichotomous, "black-or-white" thinking leads the borderline individual to either idealize or demonize others. People with Borderline Personality Disorder are known to have intense and chaotic relationships: They can also be extraordinarily charming and tend to "suck people in" and then "spit them out" just as rapidly. This chronic vacillation between the idealization and devaluation of others often results in the severe and frequent social rejection of the person with the disorder.

In the clinical setting, it is common for borderline patients to present in a state of crisis, usually interpersonal in nature, with volatile and changing moods demonstrated throughout the session. Unsure of who they are at their core, and unable to tolerate and regulate negative emotions internally, they desperately seek the attention and support of others, and frantically seek to avoid real or imagined abandonment. However, because of a chronic inner conflict between fusion with others and abandonment, they may easily reject or become hostile toward the person whom they just pulled in closer, pushing the person away only to demand his or her attention and nurtur-

ance soon after, in a vicious cycle. Individuals with this disorder are typically experienced by others as compellingly painful to relate to. An additional feature is that those with this disorder may have brief periods of paranoia or dissociation when stressed, but otherwise their contact with reality is generally well maintained.

People with Borderline Personality Disorder are typically high users of psychiatric services (both inpatient and outpatient; Serin & Marshall, 2003) and can be a drain on mental health systems. Hollywood portrayals of Borderline Personality Disorder have appeared in several popular films including Fatal Attraction and Single White Female, demonstrating the often dramatic and severely dysfunctional nature of this disorder. Certainly, this disorder is among the more florid, provocative, and evocative of the personality disorders, and the pathology can be highly seductive. The DSM-IV-TR diagnostic criteria for Borderline Personality Disorder are shown in Table 3.2.

Potential Age-Bias of Criteria

Several experts have suggested that Borderline Personality Disorder is the most difficult personality disorder to accurately identify and diagnose in later life due to limitations in the diagnostic criteria to capture the manifestations of the disorder among older adults. In fact, there is considerable debate whether the disorder declines with age. Cross-sectional studies documenting lower levels of Borderline Personality Disorder in older versus younger persons (e.g., Coolidge, Burns, Nathan, & Mull, 1992; Segal, Hook, & Coolidge, 2001) may indicate a veridical decline in borderline symptomology across the life span. A competing explanation, however, is that the diagnostic criteria are inadequate in detecting manifestations or signs of the disorder in older adults (Rosowsky & Gurian, 1991, 1992). Reflecting on the lower prevalence of the disorder in older adults, Rosowsky and Gurian (1991) have suggested that this "could reflect more the lack of fit of our existing diagnostic yardsticks than the lack of Borderline Personality Disorder in old age. If there are individuals with Borderline Personality

Table 3.2 DSM-IV-TR Diagnostic Criteria for Borderline Personality Disorder (Code: 301.83)

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

(4) 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

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

(6) 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)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

Source: From Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, American Psychiatric Association, 2000, Washington, DC: Author. Copyright 2000 by American Psychiatric Association. Reprinted with permission.

Disorder in old age, as clinicians know there are, then we need to adapt our yardsticks to be able to identify them" (pp. 39-40). Several of the specific DSM-IV-TR criteria seem awkward or inappropriate in the context of later life and these are discussed next.

Criterion 1 (frantic efforts to avoid real or imagined abandonment) makes little sense in the case of physically frail older adults who must rely on care from others to meet their basic needs. Abandonment in this context can have catastrophic consequences, and as such, efforts to avoid it can reasonably reach frenzied proportions. We have seen the pattern in which aging individuals with Borderline Personality Disorder are extremely fearful of abandonment by their caregivers, constantly checking in with them and upping the ante of dependency. Criterion 3 (identity disturbance) does not apply well in cases when, for example, older adults (primarily women in the current cohort) seek psychotherapy because their lifelong role as a caregiver (to their spouse and children) no longer is necessary (e.g., after the spouse has died and the children have left the family home). We have seen many cases wherein older women in this situation have felt as if they "do not know what to do with themselves" and that they no longer have a strong sense of identity, direction, or purpose. What distinguishes this case from Borderline Personality Disorder is that the struggle to define oneself makes sense in the developmental context of role loss and does not reflect a core lifelong deficit in identity formation.

Criterion 4 (impulsivity in at least two areas that are potentially self-damaging) and Criterion 5 (recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior) may also be a poor fit among older adults. As noted, impulsive behaviors naturally decline with advancing age. As such, some aging individuals with Borderline Personality Disorder may not show this particular sign. In an interesting study, Stevenson, Meares, and Comerford (2003) did indeed find diminished im-pulsivity in older patients with Borderline Personality Disorder compared to younger patients with the disorder. Another issue about these two criteria is that of mortality effects: People with severe expressions of these dangerous behaviors are at increased risk for early death. Thus, the lower prevalence rates in cross-sectional studies may not reflect declines in the symptoms over time but rather selective early mortality for some severe cases. These particular symptoms are also of concern in the clinical context as such behaviors in frail elderly can be fatal, even if the person did not intend to hasten death.

Finally, Criterion 6 (affective instability due to a marked reactivity of mood) and Criterion 8 (inappropriate, intense anger or difficulty controlling anger) may not apply well to some individuals in later life because of the natural tendency for older adults to become better at regulating and controlling their emotions. However, the available data suggest that, throughout the life span, affective instability and poorly controlled anger continue to be diagnostic benchmarks. These two features seem to be robust across the life span and effectively discriminate Borderline Personality Disorder from other personality disorders, even in later life (Rosowsky & Gurian, 1991).

Given the apparent problems with many (but not all) the criteria for Borderline Personality Disorder, some later-life borderlines will not be detected through routine application of the current diagnostic criteria. This puts the mental health field in a precarious catch-22 situation in forming a diagnosis: Disorders are defined by the diagnostic criteria, but if the criteria do not fit a particular group or subgroup (older adults in our examples), then those with proxy signs of the disorder cannot be formally diagnosed with the disorder, preventing further study of the phenomena and hampering treatment efforts. However, there are ways around this issue. When a patient meets four of the nine criteria for Borderline Personality Disorder (not five of nine as is required for formal diagnosis), then Personality Disorder Not Otherwise Specified may be indicated if the symptoms are pervasive and result in some impairment. A final point to understand is that because we treat people with problems (and not problems per se, in a vacuum), treatment can logically proceed and target the symptoms of personality pathology regardless of whether any diagnostic threshold is met.

Theorized Pattern in Later Life and Possible Impact of Aging

As noted, selective premature mortality due to risky behaviors and completed suicide serves to reduce rates of Borderline Personality Disorder in later life. Among those with this disorder in later life, however, a commonly observed pattern is for some of the symptoms to be significantly attenuated or "burned out" over time. One can imagine that the intense rage, physical fights, substance abuse, sexual acting out, self-mutilation, and other impulsive and physically punishing and taxing behaviors will be muted among many older adult sufferers. These behaviors seem to be either transcended or transmuted somewhere between early adulthood and old age (Rosowsky & Gurian,

1991). An example of a core symptom hypothesized to manifest differently in later life is anorexia, which may be a substitute for more obvious and provocative forms of self-mutilation seen in younger patients. Other geriatric variants of self-harming behaviors may include self-prescribed polypharmacy, refusal of needed medical attention, or sabotage of medical care (Rosowsky & Gurian, 1992). Changes in the phenomenology of identity disturbance manifest in later life as an inability to formulate future plans or pursue goal-directed behaviors (Rosowsky & Gurian, 1992). In contrast to expressions of the disorder likely to undergo age-related metamorphoses, some symptoms may be expressed similarly throughout life. Indeed, it seems unlikely that the effects of aging alone will have much impact on Borderline Personality Disorder features including chronic feelings of emptiness, unstable and intense interpersonal relationships, emotional lability, anger dyscontrol, and the reliance on splitting and other primitive defenses. Without intervention, these features will likely persist into later life. In some cases, the symptoms may even become more pronounced.

Increased dependency is a particular challenge likely to impact the aging individual with Borderline Personality Disorder. Older adults with the disorder are known to cause havoc on their move to assisted living facilities, rehabilitation hospitals, or skilled nursing facilities. They may intensely attach themselves to unsuspecting residents only to turn against them in a brief period. The borderline type is expert at turning people against each other (including staff) and generally creating chaos in relationships.

Older adults with this disorder will also likely have trouble negotiating relationships with caregivers. We have often seen the pattern where these individuals identify one or two professionals as the "good ones" and vehemently complain about and reject help from others, the "bad ones." To make matters worse, their preferences may change abruptly, which can confuse and anger the staff. Due to their underlying difficulties regulating interpersonal distance, older adults with Borderline Personality Disorder are also likely to struggle between wanting closeness and angrily rejecting it from caregiving staff. Another pattern may be attempts at manipulation of caregiving staff by distorting information about their past medical history or their compliance with medical and rehabilitative regimens. Their angry entitlement may serve to engender anger in the caregiving staff, or alternatively, helpless frustration (Rosowsky & Gurian, 1992).

A final aging issue is that many older adults with Borderline Personality Disorder come to later life with a minimal (or nonexistent) social support network. Many of them have worn out family members during a lifetime of crises and poor boundaries. Thus, aging in general can be viewed as extremely challenging for those with Borderline Personality Disorder. Individuals with this personality pathology perhaps are the least prepared to cope with the usual changes and stressors that accompany the late-life stage. Sadly, their relationships with psychotherapists are at great risk for mirroring the unstable and tumultuous patterns they enact with others. They are likely to foster splitting and specialness, and evoke negative countertransference reactions (Rosowsky & Gurian, 1991). A general tenet for the clinician is to be a model of stability, neither moving in too close to rescue patients who appear helpless and lost nor withdrawing and rejecting patients even when they seem to be asking for it.

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