Borderline Personality Disorder

“And only in the Remembrance of Allah will the hearts find tranquility” Holy Quran (13: 29)

Introduction
Borderline Personality Disorder (BPD) is a psychiatric personality disorder. It is so termed because these patients always seem to be hanging on the border between normal people or psychos, such are there behavioral and mood swings. From being perfectly all right in one second to being totally bizarre in the next second. They keep their audiences well awake most of the day!

Etiology
Borderlines are born with an innate biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. They peak “higher” emotionally on less provocation and take longer coming down. In addition, they were raised in environments in which their beliefs about themselves and their environment were continually devalued and invalidated. These patients most likely experienced a lot of physical as well as psychological trauma/violence during much of their childhood & they were mostly helpless against the continued verbal & physical abuse.

Criteria for Diagnosis
• Intense unstable relationships in which the borderline always ends up getting hurt. One has to hesitate in diagnosing a patient as BPD without its presence.
• Repetitive self-destructive behavior, often designed to prompt rescue.
• Chronic fear of abandonment and panic when forced to be alone.
• Distorted thoughts/perceptions, particularly in terms of relationships and interactions with others.
• Hypersensitivity, meaning an unusual sensitivity to nonverbal communication.
• Impulsive behaviors that often embarrass the borderline later.
• Poor social adaptation: in a way, borderlines tend not to know or understand the rules regarding performance in job and academic settings.

Further Borderline characteristics
1. Affect
Chronic/major depression, helplessness, hopelessness, worthlessness, guilt, anger, anxiety , loneliness , boredom, emptiness
2. Cognition
odd thinking, unusual perceptions, non-delusional paranoia (thinking that others are harming/planning to harm him)
3. Impulse action patterns
Substance abuse/dependence, sexual deviance, manipulative suicide gestures, other impulsive behaviors e.g. drinking, gambling,
4. Interpersonal relationships
Intolerance of aloneness. Fear of abandonment, engulfment, annihilation fears, stormy relationships, manipulativeness, dependency , devaluation, masochism/sadism, demandingness, entitlement

Borderline Traits
Traits involving emotions:
Quite frequently people with BPD have a very hard time controlling their emotions. They may feel ruled by them. One researcher said, “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.”
1. Shifts in mood lasting only a few hours.
2. Anger that is inappropriate, intense or uncontrollable.
Traits involving behavior:
3. Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once
4. Two potentially self-damaging impulsive behaviors. These could include alcohol and other drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.
Traits involving identity
5. Marked, persistent identity disturbance shown by uncertainty in at least two areas. These areas can include self-image, sexual orientation, career choice or other long-term goals, friendships, values. People with BPD may not feel like they know who they are, or what they think, or what their opinions are, or what religion they should be. Instead, they may try to be what they think other people want them to be. Someone with BPD said, “I have a hard time figuring out my personality. I tend to be whomever I’m with.”
6. Chronic feelings of emptiness or boredom. Someone with BPD said, “I remember describing the feeling of having a deep hole in my stomach. An emptiness that I didn’t know how to fill. My therapist told me that was from almost a “lack of a life”.
Traits involving relationships
7. Unstable, chaotic intense relationships characterized by splitting.
8. Frantic efforts to avoid real or imagined abandonment
• Splitting: the self and others are viewed as “all good” or “all bad.” Someone with BPD said, “One day I would think my doctor was the best and I loved her, but if she challenged me in any way I hated her. There was no middle ground as in like. In my world, people were either the best or the worst. I couldn’t understand the concept of middle ground.”
• Alternating clinging and distancing behaviors (I Hate You, Don’t Leave Me). Sometimes you want to be close to someone. But when you get close it feels TOO close and you feel like you have to get some space. This happens often.
• Great difficulty trusting people and themselves. Early trust may have been shattered by people who were close to you.
• Sensitivity to criticism or rejection.
• Feeling of “needing” someone else to survive
• Heavy need for affection and reassurance
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
This means feeling “out of it,” or not being able to remember what you said or did. This mostly happens in times of severe stress.

Mass Awareness & Vigilance of BPD
1. Public Awareness: The public should be taught these basic criteria for diagnosing a patient of BPD so that the person him or herself tries to seek treatment (which is very rare) or his family members seek treatment for him/her.
2. Vigilance: Be on lookout for Borderline: If you know anyone in your immediate or near family, your neighbors, your friends, your colleagues or any other acquaintances who you suspect most likely fulfill these criteria, then seek immediate treatment/contact health administrator/NGO

Treatment of BPD
Since this personality disorder brings the most suffering for the patient himself as well as his close ones, treatment is immediately required. It maybe the only way of saving a stormy marriage or a broken family. One thing that the family members or close ones can remain assured about: the person with BPD in reality loves them and cannot live without them; he doesn’t behave like this with people who he doesn’t love; so one should never let go of these people that easily: SEEK TREATMENT!

Psychological Treatment:
This includes different types of behavioral therapy including cognitive therapy. Cognitive therapy tries to change how a person thinks and involves talk therapy that focuses on helping the person understand how their thoughts and behaviors affect each other.
Other types of psychotherapy include interpersonal and psychoanalytical therapy.

Pharmacological Therapy:
The use of psychiatric treatment medications, like antidepressants (for example, fluoxetine , sertraline , citalopram, escitalopram , venlafaxine , duloxetine, or trazodone , mood stabilizers (for example, divalproex sodium , carbamazepine , or lamotrigine , or antipsychotics (for example, olanzapine , and risperidone may be useful in addressing some of the symptoms of BPD but do not manage the illness in its entirety. However there is increased tendency to commit suicides with medications. Partial hospitalization is an intervention that involves the individual with mental illness being in a hospital-like treatment center during the day but returning home each evening.

Best Treatment:
Obviously the best treatment is cognitive & spiritual therapy from reading the Holy Quran/Bible, remembering God in zikr (remembrances) and in prayers especially Tahajjud (late night prayers) and seeking his forgiveness.

Famous People with BPD:
As someone once said “Nations sometimes tend to suffer personality disorders as a whole, en masse”. Well, it certainly goes true for Pakistan for it seems the nation as a whole may be suffering from Borderline Personality Disorder! Our leaders surely made some impulsive decisions like President Musharraf! It is however much under-diagnosed in this country due to scarcity of psychiatrists as well as lack of public awareness and the sense of shame attached with visiting a psychiatrist.
(Late): Lade Diana, Angelina Jolie, Britney Spears are famous personalities with BPD.

Books Recommended on BPD
1. I Hate you, don’t leave me by Randi Kreger
2. Sometimes I act crazy by Jerold Kreisman
3. Get me Out by Rachael Reiland
4. Treatment of BPD by Joel Paris

By the way, how many of you are thinking you have BPD after reading this article?

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