Personality Disorders are a type of mental illness that includes a wide range of problems dealing with the world at large, and a number of perception problems that make living an ordinary modern life very difficult for the sufferers. There is a certain stigma attached to these kinds of disorders that often keeps sufferers from seeking treatment. The name applied to this group of disorders is misleading, since "personality," in common usage, tends to connote some kind of control or willfulness on the part of the sufferer – this leads many people to think that the sufferer is somehow at fault for the illness. However, we are now learning that many patients under new drugs and treatments may gain some level of control over their illness (Kaplan & Sadock, 791). Until recently most personality disorders were treated either through therapy or a combination of therapy and pharmacologic intervention. However, compliance has long been an issue with this group of illnesses because the available medications had severe side effects that often dulled the senses and led to an uncomfortable apathy. New medications and vastly varied methods of psychological treatments where the emphasis is on helping the client acquire personal control over the symptoms have had promising results. This is finally bringing new hope to sufferers of a widely misunderstood group of mental illnesses, and may bring them out of the shadows into a new more satisfying life for them and those that interact with them regularly (Oxford, 458).
Borderline Personality Disorder (BPD) is an Axis-II diagnosis. The hallmarks of a BPD diagnosis are that the patient always seems to be in a state of crisis with frequent, uncontrollable mood swings. Patients may have minor psychotic breaks, often termed micro psychotic episodes. These patients are unpredictable and tend to be underachievers. Patients run the gambit from dependency to open hostility and unsurprisingly have trouble in interpersonal relationships. They have an intolerance of being alone and they prefer a companion, no matter how substandard they are – often befriending strangers and acting promiscuously. Kerberg described a primitive defense mechanism engaged in by these patients termed “projective identification” whereby the negative self-traits are projected on another. They have normal intelligence and show abnormalities on unstructured projection tests, like a Rorschach test. (Kaplan & Sadock, 800).
The 4th edition of the Diagnostics and Statistics Manual (DSM-IV) lists the criteria of a BPD diagnosis. The criteria include “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning in 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, 2) a pattern of unstable and intense interpersonal relationships, 3) identity disturbance, 4) impulsivity in at least two areas that are potentially self-damaging, 5) recurrent suicidal behavior, 6) affective instability, 7) chronic feelings of emptiness, 8) inappropriate, intense anger, or difficulty controlling anger, 9) transient, stress-related paranoid ideation (DSM-IV).
BPD is believed to occur in about 1-2% of the population and is twice as common in women. There are many co-morbidities associated with the disease, including, depressive disorders, substance abuse disorders, and post-traumatic stress disorder (Kaplan & Sadock, 799). The co-morbidities are made more difficult to manage because of the presence of BPD and extra care and attention should be taken with regard to the treatment modalities administered due to this fact.
Clinically, BPD patients always seem to be in a crisis and may be argumentative one moment, depressed another, and euphoric shortly after that. Patients often view people as either being all good, or all bad, and do not see shades of grey in humanity. Due to this splitting, “good people” are idealized and “bad people” are devalued (Kaplan & Sadock, 800). Social interactions in BPD patients are often blunted compared to healthy control subjects (Lis & Bohus). When using a wide variety of questionnaires to assess the patients, including self-ratings, interviews, directed interviews, functional assessments, and relationship theme assessments, it is noted that patients often have more negative views of interactions than normal and have higher intra-individual variability (Lis & Bohus). In the context of social rejection, BPD patients have much worse coping mechanisms and show dysfunctional behavior. Furthermore they repeatedly show modalities of low self-esteem or a deficiency of control of executive functions (Lis & Bohus). Another experiment tried with BPD patients involved trust games designed to measure respondent’s levels of social cooperation. BPD patients repeatedly scored lower in these games than healthy subject, and interestingly, when they were dosed with oxytocin (a peptide that plays an important role in pro-social behavior,) they showed even less trusting behavior (Lis & Bohus). Finally, with regards to hostility and aggression, it has been shown that BPD patients have low glucose metabolism in the amygdala and orbitofrontal cortex, which suggests a biological basis for increased aggression and hostility (Lis & Bohus).
The patients present a variety of ethical and clinical problems to the practitioner due to the fact that suicidal behavior is a hallmark of diagnosis. The first question is whether or not the practitioner should even tell the patient about their diagnosis. Psychiatrists have feared that the stigma associated with the diagnosis would impair the relationship and give a sense of abandonment to the patient (Howe, 15) However, today, it is commonly accepted practice to share the diagnostic information with the patient in the belief that it aids in the development of the relationship between practitioner and patient and may serve as a guide to help the patient understand the stresses that they feel (Howe, 15). Another question that has arisen is the discussion of the increased risk of suicide in these patients. Disclosing the risk displays a respect for the patient, however, psychiatrists have feared putting ideation into the patients head and that it might cause the patient to have a more exaggerated sense of hopelessness. Ultimately, the answer relies on the practitioners feelings about the patient and whether he thinks that disclosing the risk will somehow benefit the patient (Howe, 16). To what extend the psychiatrist will be available by telephone to help the patient is also something that must be considered and discussed with the patient. The psychiatrist must be available to talk the patient down from suicidal ideation on the one-hand, but on the other, the very realistic stress of being on-call day and night is damaging to the practitioner himself. Furthermore, some patients may call too often because they lack the capacity to differentiate serious feelings from more remote ones. Finally, it is important to note that BPD patients are often more likely to have suicide attempts when they are less depressed, perhaps because they have more energy. In any case, a patient may not call his psychiatrist at this time due to their feeling better (Howe, 16). Howe also discusses the possibility of involuntary hospitalization of a BPD patient (17). In order to mitigate the liability associated with such hospitalizations it important to discuss the problem with the patient, and to discuss the patient with colleagues and to document everything decided upon. The ethical dilemma comes in part because hospitalized patients will have higher suicide risks later in exchange for a short term safer environment (17). When a patient has attempted suicide and failed while under treatment presents another challenge to the relationship. Some psychiatrists will end the relationship immediately while others will attempt to work around it. The ethical fear is the issue of liability for a patient that successfully terminates their life. It is important in these cases for the psychiatrist to make an honest assessment of his treatment to determine if he failed (Howe, 17).
Various treatments exist for BPD patients and the modalities include both psychotherapy and pharmacotherapy. To use one to the exclusion of the other is bad practice, and it is impossible to make broad statements as to which should be tried first as every patient must be handled differently. For instance, a stable patient whom a psychiatrist is seeing for the first time can be out on a psychotherapy regimen, however, a patient who has attempted suicide recently should be put on pharmacotherapy immediately. Therapy is difficult for both the patient and practitioner for reasons noted previously. The mainstay of the psychotherapeutic approach has been dialectical behavioral therapy (Kaplan & Sadock, 801). Pharmacotherapy is dependent on the patients symptom constellations but can include any combination of antipsychotics, antidepressants, MAOIs, benzodiazepines, anticonvulsants and SSRIs (Kaplan & Saddock, 801). A relatively new treatment modality is schema therapy, which was developed by Young. Schema therapy involves attempts to untangle maladaptive schema that the patient has developed as coping mechanisms when presented with adversity. Schema therapy is a branch of Cognitive Behavioral Therapy and uses a concept of “limited re-parenting” in its attempts to redirect the patients mind and the schema that it uses in order to cope with adversity. Essentially, Schema therapy holds that personality disorders come about due to core needs of a child not being met, and attempts to re-find those experiences where the needs have been met – with the ultimate goal of finding “secure attachment.” In the process of “emphatic confrontation,” limited re-parenting may be either tender or confrontational, depending on the needs of the patient that the practitioner is able to identify. (Young) Traditional cognitive interventions, psychodramas, and behavioral therapy are also used, but the limited re-parenting is the unique contribution of schema therapy. Another aspect of the theory is the idea that children experience early relationships through imagery and consequently utilize the right hemisphere of the brain. The maladaptive schema are believed to be stored in the right hemisphere of the brain and due to strong links with the limbic system make for a particularly emotional embodiment of early maladaptive schema (Young). Thus, guided imagery is often used during therapy in order to get a clearer understanding of the schema mode that is being explored. The patient can employ Flashcards as reminders of the psychiatrist’s messages with the goal being internalization of the message. Chair work is another method of behavioral therapy used in schema therapy, whereby the patient plays out a dialogue between the mode of Healthy Adult and the pathological schema mode that is present. Finally, patients also employ diaries in-between therapy sessions in order to organize their experiences when the maladaptive schemas are triggered (Young). The value of schema therapy and its empirical foundation were confirmed in an article by Sempértegui, et al. in 2013.
In sum, BPD may present in terrifying ways that disorder the patients social life and the lives of people associated with the patient. The swings of the disease are manageable by careful consideration of the practitioner. In time, patients have a reasonably good prognosis with about half of the patients essentially becoming cured. However, the persistence of the disease and the effects that it has on the treatment of other diseases can not be ignored and is at the heart of what makes research into the area so important.
Works Cited
Howe, Edmund. “Five Ethical and Clinical Challenges Psychiatrists May Face When
Treating Patients with Borderline Personality Disorder Who Are or May Become Suicidal.” Innovations in Clinical Neuroscience 10 (2013):14-19. Print.
Lis, Stefanie & Bohus, Martin. “Social Interaction in Borderline Personality Disorder.”
Current Psychiatric Reports 15 (2013): 338. Online. DOI 10.1007/s11920-012-0338-z
Sadock, Benjamin James, and Sadock, Virgina Alcott. Kaplan & Sadock’s Synopsis of
Psychiatry. 10 ed. New York: Lippincott Williams & Wilkins, 2007. Print.
Sempértegui, Gabriela A., et al. “Schema therapy for borderline personality disorder: A
comprehensive review of its empirical foundations, effectiveness and implementation possibilities.” Clinical Psychology Review 33 (2013): 426-447. Online http://dx.doi.org/10.1016/j.cpr.2012.11.006
Semple, David, et al. Oxford Handbook of Psychiatry. Oxford: Oxford University Press,
2005. Print.
Young, Jefferey E., et al. Schema Therapy: A Practitioner's Guide. New York: Guilford
Press, 2003. Print
