BORDERLINE PERSONALITY DISORDER

From the early days of being considered a variant of schizophrenia, somewhere on a spectrum between psychotic and neurotic, the symptom cluster of Borderline Personality Disorder (BPD) has evolved considerably. Grinker (1968) described the

‘borderline syndrome’, which included failure of identity, turbulent relationships, depression based on loneliness, and predominance of expressed anger. Throughout the 1970’s the concept evolved through clinical observations and research and was eventually recognised as a distinctive diagnostic category by DSM-III in 1980 (APA, 1980). The disorder steadily gained recognition and the diagnosis was made more reliably through improved psychometrics. By the 1990’s onwards, BPD became among the most controversial diagnoses, with many debates unresolved (Zittel &

Westen, 1998) and misunderstandings still in existence (Hersh, 2008).

In Chapter Two, the classification of the disorder, its epidemiology, its course, and suicidal and self-injurious behaviours in BPD is discussed. The complexities of co-morbidity in BPD and the challenges made to its diagnostic value are then elaborated.

An outline of the major aetiological perspectives of BPD is given. Staff reactions to the condition and therapeutic options forms the final discussion. From this analysis of all the latest literature on BPD, the intricacies of BPD and how there is both an evolving understanding of the concept and yet still many questions left not fully answered are demonstrated. The immense difficulties of treatment of BPD, heavy service usage and often restrictive staff views of the disorder are highlighted. Finally, the seriousness, pervasiveness and chronicity of the self destructive and suicidal component of the disorder are emphasised, as well as the incapacitating emptiness, turbulent relationships, violent mood changes, identity disturbance and impulsivity that impacts so immensely on the person themselves and their families.

2.1 EVOLUTION OF THE CONCEPT

A personality disorder is described in the International Classification of Mental and Behavioural Disorders (ICD-10) as “deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of social and personal situations, representing either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others” and are “developmental conditions appearing in childhood or adolescence and continue into adulthood” (World Health Organisation, 1992a).

Personality disorders are divided into Cluster A (odd and eccentric disorders including paranoid, schizoid and schizotypal personality disorders), Cluster B (dramatic, emotional and erratic disorders including antisocial, borderline, histrionic and narcissistic personality disorders), and Cluster C (anxious/fearful disorders namely avoidant, dependent and obsessive compulsive personality disorders).

Diagnostic Statistical Manual-IV or DSM-IV (APA, 1994) defines Borderline Personality Disorder (BPD) as the following “a pervasive pattern of instability of interpersonal relationships, self image and affects, and a marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following…”.

 Frantic efforts to avoid real or imagined abandonment.

 A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.

 Identity disturbance; markedly and persistently unstable self-image or sense of self.

 Impulsivity in at least two areas that are potentially self-damaging (e.g.

spending, sex, substance misuse, reckless driving, binge eating).

 Recurrent suicidal behaviour, gestures, or threats, or self mutilating behaviour.

 Affectivity 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).

 Chronic feelings of emptiness.

2.2 DIAGNOSIS AND CLASSIFICATION

 Inappropriate, intense anger or difficulty controlling anger (frequent displays of temper, constant anger, recurrent physical fights).

 Transient, stress-related paranoid ideation or severe dissociative symptoms.

2.3.1 PREVALENCE

Studies have cited BPD rates of approximately 0.4% to 1.8% among community samples (Maier, Lichertermann, Klinger, Heun & Hallmayer, 1992; Samuels, Nestadt, Romanoski, Folstein & McHugh, 1994; Swartz, Blazer & Winfield, 1990; Torgensen, Kringlen & Cramer, 2001) and 10% to 25% among clinical samples (APA, 1994;

Gunderson & Zanarini, 1987; Widiger & Weissman, 1991). The method used to assess BPD has a great impact on the frequency with which it is diagnosed (Zimmerman & Mattia, 1999). Hence, use of different assessment tools (clinician scored or self report) with varied psychometric quality, sampling method and population chosen all influence the prevalence rate reported.

2.3.2 GENDER

BPD is more often diagnosed in women. Two thirds to three quarters of those diagnosed with BPD are women (Zanarini, Williams, Lewis, Reich & Marino, 1997).

It is estimated that 3% of females of the general population compared to 1% of the male general population have BPD. As a result, the majority of the literature focuses on its occurrence in women (Johnson et al, 2003). Johnson et al (2003) found that men with BPD were more likely to present with substance use disorders, and with schizotypal, narcissistic, and antisocial personality disorders, whereas women with BPD were more likely to present with post-traumatic stress disorder, eating disorders, and the BPD criterion of identity disturbance. The authors claimed that to date there has been very little research specifically investigating the occurrence of BPD in men.

Zanarini et al (1998) hypothesised that gender differences found in BPD may be a function of impulsivity, in that men and women may differ in the specific type of impulse they would predominately display. Women may be more likely to use food (i.e. internalising behaviours) and men alcohol and drugs and acting out against others

2.3 EPIDEMIOLOGY

(i.e. externalising behaviours) in a self destructive way. Johnson et al (2004) maintained that men and women with BPD are more similar in their clinical presentations than they are different. Other possible reasons for the gender imbalance in reported BPD prevalence rates include that diagnosis may be biased against females who are more emotionally expressive in nature than males, males may seek out professional help less frequently, males are more likely to be diagnosed with antisocial personality disorder, and the incidence of neglect, invalidation and abuse appears to be reported at a higher rate by females (Krawitz & Jackson, 2008).

2.4.1 POOR OUTCOME

For effective therapeutic management of BPD, it is important to be well informed about its prognosis, and consequently clinicians need to fully appreciate the extent and significance of functional impairment associated with BPD. Studies have demonstrated that individuals with BPD experience significant levels of maladjustment in several domains of functioning such as academia, interpersonal functioning and are more likely to meet lifetime criteria for a mood disorder (Trull, Useda, Conforti & Doan, 1997). Functional impairment, referring to psychosocial functioning such as educational impairment and job attainment, is indeed worse in BPD than in Cluster C personality disorders (anxious/fearful cluster), but is comparable to the impairment observed in equally severe schizotypal personality disorder of Cluster A (odd and eccentric cluster). Bagge et al (2004) showed that BPD features, particularly the impulsivity and affective instability, prospectively predicted negative outcomes and led to impairments in relating well with others, in meeting social role obligations, and in academic achievements in a group of 351 young adults over a two year period.

Limited studies have assessed the performance of those with BPD in educational/occupational settings. Soloff (1981) and Trull, Useda, Conforti & Doan (1997) both revealed academic deficits in those with BPD, with fewer years of education being reported and an increased likelihood of academic difficulties in those with BPD. However Zimmerman & Coryell (1989) and Torgensen, Kringlen &

2.4 COURSE OF THE DIAGNOSIS

Cramer (2001) found that community members with BPD had no less education than those who did not have BPD. There is substantially more evidence that patients with BPD have more unemployment, frequent job changes, or periods of disability compared to patients with no personality disorder or with axis I disorders. Poorer work functioning, less occupational satisfaction and achievement has been demonstrated among those with BPD compared to others (Skodol et al, 2002). In one Finish study, it was shown that 33% of the sample with BPD were continually fit for work, while 46% chronically incapable of working (Antikainen, Hintikka, Lehtonen, Koponen & Arstila, 1995).

Social functioning is also poorer in those diagnosed with BPD. An array of studies have shown that patients with BPD are more likely than others to be never married, or separated, or divorced (Soloff, 1981; Torgensen et al, 2001; Modestin & Villiger, 1989). Most studies also report poorer quality of social relationships (Skodol et al, 2002).

Measures of global functioning, such as the Global Assessment Scale (GAS), assess social and occupational functioning and are influenced by the severity of psychopathology. On measures of global functioning, patients with BPD have been found to be significantly impaired (Paris, Brown & Nowlis, 1987), as well as having a reduced quality of life (Torgensen et al, 2001).

Functional impairment in BPD appears to be more persistent and changes more gradually than the symptomatic manifestations of the disorder (Skodol, 2005, cited in Zanarini, 2005). Improvements in psychopathology are accompanied by increments in functioning, but not immediately. BPD does have severe, persistent, and pervasive impact on an individual’s life.