Borderline

Borderline personality disorder (BPD) is one of the "emotionally unstable personality disorders" that can often occur in adolescence or young adulthood. According to expert estimates, it is assumed that around 6% of young people or 1-2% of the total population in Germany suffer from borderline personality disorder.

In the past, it was assumed that young women were more frequently affected by borderline personality disorder. According to the latest research, however, it can be assumed that the gender distribution is fairly even. About 70% of patients in therapy are female - male sufferers may be more prone to violence, which is why, according to studies, they are more likely to be in juvenile detention facilities than in therapeutic settings.

Borderline patients usually suffer from severe mood swings and emotional storms. To escape this tension for a time, many sufferers exhibit forms of self-destruction, such as self-harm, use of drugs, eating disorders, or engaging in high-risk sports. Many patients also exhibit a strong sense of self-hatred, with their own body becoming a rejected object.

As the intensity of these emotions can sometimes be very strong, many sufferers lose the feeling for their own body, standing beside themselves and no longer perceiving reality. This condition is called "dissociation" by doctors.

Borderline patients also suffer from not being able to control their own impulses. Even small things can upset them. This is especially the case when they are prevented from acting out their impulses. This behaviour can easily bring them into conflict with their environment and their fellow human beings. They may have an unstable self-image, which can easily falter. This can make it increasingly difficult for them to pursue goals, as their plans can change more quickly.

People or circumstances may be idealised at one moment and strongly devalued at a slight disappointment. Many sufferers may have difficulty completing vocational training.

On average, the severity of the disorder diminishes by the age of forty and the violence of the emotional storms subsides. Borderline usually occurs in conjunction with other illnesses. For example, many patients also suffer from depression, panic disorder, post-traumatic stress disorder and alcoholism to some extent.

Implementing Creativity:

Since borderline personalities have an intense emotional life, they can sometimes implement it creatively. For this reason, they can also be talented musicians, actors or painters.

The causes of borderline personality disorder are still largely unexplored. However, it is believed that an interaction of genetic predisposition, biological factors and adverse experiences can trigger the disorder.

Trauma can contribute significantly to the development of borderline personality disorder. For example, 65% of those affected are thought to have experienced sexual abuse in childhood, particularly within the family. According to analyses, 60% have come into contact with physical violence.

Mental abuse can also increase the risk. 40% of those affected are reported to have experienced a lack of affection in family relationships during their youth or to have come into contact with unpredictable caregivers. Early experiences of separation in the form of divorce or the death of a parent can also increase the risk. In general, it can be assumed that psychological problems in the family, such as alcohol abuse, depression or schizophrenia, increase the risk of a personality disorder.

Nevertheless, the family is not always the trigger for a borderline personality disorder. Some personality disorders develop even without distressing experiences within the family.

Recent research shows that communication between certain brain centers responsible for emotional processing is disrupted in people who suffer from borderline. This may be the reason why feelings are perceived much more intensely by borderline patients than by non-affected persons. However, it is not clear whether this tendency has been present since birth or only arises as a result of traumatic experiences.

Typical symptoms include:

• Impulsive behavior patterns, such as frequent tantrums or aggressive outbursts.
• Severe mood swings
• Unstable interpersonal relationships that may nevertheless be intense
• Self-harm and suicide attempts
• Identity crises, changeable life plans
• Some sufferers have the feeling of being temporarily outside of their own body (depersonalisation experiences)
• Other self-harming behaviours such as eating disorders, promiscuity, or drug use.

To ensure a reliable diagnosis, an accurate medical history is essential. This should include the following questions:

• Did the symptoms already become apparent in childhood or adolescence.
• Are the symptoms characteristic of the person in question (for example, aggressive behaviour towards both the mother and classmates).
• Do these symptoms occur in different life situations.
• Is the level of distress felt to be very high.

The anamnesis also includes a questioning of the reference persons and here above all of the parents. In order to diagnose borderline, other mental disorders with similar symptoms, such as schizophrenia or social behaviour disorder, must be excluded.

Personality disorders are characterized by significant deviation from culturally expected and accepted norms in at least two of the following areas:

• Cognition: the environment and personal surroundings are interpreted differently by affected individuals.
• Affectivity: Their emotions are often exuberant and more intense. This often leads to inappropriate reactions.
• Impulse control: sufferers find it difficult to keep their impulses under control, which is why they can have the urge to satisfy needs immediately.
• Relationships: They often develop a dysfunctional relationship with their fellow human beings.

Furthermore, the doctor or therapist asks about typical symptoms of a borderline personality disorder, such as complicated relationships, life crises, aggression and self-harm.

For a diagnosis of borderline, at least two of the following characteristics must apply (according to ICD 10):

• A tendency to act without consideration of consequences and unexpectedly (lack of impulse control).
• Tendency to quarrel and conflict with others, especially occurring when impulses are suppressed or rebuked
• Tendency to tantrums or violence with loss of control over explosive behavior
• Problems completing an action when it is not immediately rewarded
• Moody mood swings and emotional states (affect instability).

In addition, one of the typical characteristics must be met in order to diagnose borderline disorder:

• Disturbances and insecurity regarding self-image, as well as goals and preferences.
• Tendency to enter into an unstable but intense relationship that may result in an emotional crisis.
• Intensive efforts to avoid abandonment.
• Self-harm, suicide threats and attempts.
• Constant feeling of emptiness

The therapy of borderline patients was problematic for a long time. This was due to the fact that borderline personalities tend to idealize other people, and thus also the therapist or doctor, in the beginning and then suddenly devalue them at the slightest disappointment. This results in a frequent change of therapist.

In the meantime, however, great progress has been made in borderline therapy. If patients are in an acute state with self-injurious behaviour or suicidal thoughts, an inpatient stay is unavoidable. Otherwise, outpatient care is also possible.

Dialectical Behavioral Therapy (DBT):

This therapy can be traced back to US American Marsha Linehan, who developed Dialectical Behavioral Therapy (DBT) specifically tailored to Borderline. This therapy is considered a special form of cognitive behavioral therapy.

The first phase of therapy is aimed at stabilizing the patient. The focus is on strategies that prevent the patient from self-harming behavior and a premature termination of therapy. In group therapy, the aim is then to train new ways of behaving and thinking:

• Improving the perception of oneself and others.
• Dealing with crises and self-control are practiced
• Strong black and white thinking is minimized
• Stress management and the control of one's own feelings are learned.

The second phase of the therapy focuses on the stressful life events. Here, the traumatic events are not relived and worked through as in a psychoanalytically based therapy, but rather these experiences are to be accepted as part of the personal, but completed past.

In the third phase of therapy, what has been learned is to be applied in everyday life, self-esteem is to be raised and personal life goals are to be set and turned into action.

Psychodynamic-conflict-oriented psychotherapy:

Psychodynamic therapy methods offer another option for borderline patients in addition to behavioral therapy. The effectiveness is proven by studies, which, however, only apply to adult patients. This form of therapy has its origins in psychoanalysis, which is why the focus here is on insight in connection with the experiences made and current problems relating to relationships and behaviour. The goal is a psychological reappraisal of the traumatic experiences.

In this form of therapy, particular emphasis is placed on the following points:

• Coping with trauma
• Strengthening or building up the self-image of the person affected
• Reduce problems in the ability to relate
• Minimizing black-and-white thinking
• The ability to control one's own feelings and impulses (affect regulation)

Medication therapy:

To regulate strong emotional outbursts, many borderline patients are given medication. This group of patients includes those with very severe anxiety, depression, or those who cannot control their impulses or are particularly aggressive toward those around them or themselves.

Family therapy:

This therapy is especially important when the sufferer is still in their teens. This makes it easier for the relatives to deal with the affected person. Moreover, the involvement of the family is an essential prerequisite for the affected person to change harmful patterns of thinking and behaviour.

If the origin of the personality disorder lies in the family, family therapy is even unavoidable. This is also the case if there are pathological relationship patterns in the family.

For a long time, borderline patients were not considered treatable cases. In the meantime, this view is no longer current, as therapies specifically tailored to borderline have been developed.

According to a US study, after two years only 65% of those examined still suffered from the usual borderline diagnostic criteria (DSM-IV). Four years later, this figure dropped to 32% and after a further ten years to 12%. The recidivism rate was set at around 6% and is considered to be extremely low.

However, these data should be viewed with caution, as one cannot assume a cure if only the criteria for borderline are no longer met. Problems with emotional control and difficulty integrating socially may persist. The chances of recovery are reduced if the affected person also suffers from drug or alcohol abuse. This is closely followed by patients who are affected by post-traumatic stress disorder or who were exposed to sexual abuse as children. The suicide rate among borderline patients is estimated at 5-10%.

Experts still consider the care of borderline patients to be inadequate. This is especially true for outpatient care. The reason for this is a lack of trained professionals and the non-guaranteed funding by the health insurance (in Austria) if the treatment takes longer than one year.