March 27, 2011

• I hate you, don’t leave me

  

  Borderline Personality Disorder (BPD) is a serious and often life-threatening disorder that is characterized by severe emotional pain and difficulties managing emotions. The problems associated with BPD include impulsiveness (including suicidality and self-harm), severe negative emotion such as anger and/or shame, chaotic relationships, an extreme fear of abandonment, and accompanying difficulties maintaining a stable and accepting sense of self

  Completed suicide occurs in 8%-10% of individuals with this disorder, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent job losses, interrupted education, and broken marriages are common.

  Very stressful or chaotic childhoods are commonly reported (e.g., physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation). Mood disorders, Substance-Related Disorders, Eating Disorders (usually Bulimia), Posttraumatic Stress Disorder, Attention-Deficit/Hyperactivity Disorder, and other Personality Disorders frequently co-occur with this disorder.

  Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling and recklessness in general.

  Individuals with BPD are at high risk of developing other psychological disorders such as anxiety and depression. Other symptoms of BPD, such as dissociation, are frequently linked to severely traumatic childhood experiences, which some put forth as one of the many root causes of the borderline personality.

  The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B) as:

  A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as 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-injuring behavior covered in Criterion 5
         2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called splitting.
         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., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
         5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself.
         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 anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
         9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

  It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

  When comparing individuals diagnosed with BPD to those diagnosed with other personality disorders, the former showed a higher rate of also meeting criteria for:
  anxiety disorders
  mood disorders (including clinical depression and bipolar disorder)
  eating disorders (including anorexia nervosa and bulimia)
  dissociative disorders
  Gender identity disorder
  Schizoid disorders

  Numerous studies have shown a strong correlation between child abuse, especially child sexual abuse, and development of BPD. Many individuals with BPD report to have had a history of abuse and neglect as young children. They were also much more likely to report having caregivers (of both genders) deny the validity of their thoughts and feelings.

  I Hate You, Don’t Leave Me by Jerry Kreisman, M.D. From page 10: 
  

  The world of a BP, like that of a child, is split into heroes and villains. A child emotionally, the BP cannot tolerate human inconsistencies and ambiguities; he cannot reconcile anther is good and bad qualities into a constant coherent understanding of another person. At any particular moment, one is either Good or EVIL. There is no in-between; no gray area….people are idolized one day; totally devalued and dismissed the next.

  Normal people are ambivalent and can experience two contradictory states atone time; BPs shift back and forth, entirely unaware of one feeling state while in the other. 

  When the idealized person finally disappoints (as we all do, sooner or later) the borderline must drastically restructure his one-dimensional conceptionalization. Either the idol is banished to the dungeon, or the borderline banishes himself in other to preserve the all-good image of the other person.

  Splitting is intended to shield the BP from a barrage of contradictory feelings and images and from the anxiety of trying to reconcile those images. But splitting often achieves the opposite effect. The frays in the BP’s personality become rips, and the sense of his own identity and the identity of others shifts even more dramatically and frequently.

  “Expectations destroy our peace of mind, don’t they? They’re future disappointments planned out in advance.” –from A Place of Hiding by Elizabeth George

  ‘We paced along the lonely plain, as one who returns to his lost road, and until he reaches it, seems to go in vain.’ -Dante, ‘Purgatorio’ in the Divine Comedy

  “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.”
  - University of Washington psychologist Marsha Linehan

  Caterpillar: Who… are… you?
  Alice: Why, I hardly know, sir. I’ve changed so much since this morning, you see…
  Caterpillar: No, I do not C, explain yourself.
  Alice: I’m afraid I can’t explain myself, you see, because I’m not myself, you know.
  Caterpillar: I do not know.
  Alice: I can’t put it any more clearly, sir, because it isn’t clear to me.

  • 5:42 pm
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