The controversially named borderline syndrome is a chronic, recurrent and mercurial mental disorder (Paris, 1994; Sandell, 1989). Diagnosed predominantly among females (about 75%) (Widiger and Weissman, 1991), borderline personality disorder (BPD) occurs among 2% of the general population, 10% of outpatient psychiatric patients and 20% of inpatient psychiatric patients (American Psychiatric Association, 2000). The current prevalence may reflect increased incidence within the last few decades (Million, 1987, as cited in Widiger and Weissman, 1991).
Such an increase in incidence may relate to the current zeitgeist, just as the now rarely seen grande hysterie, a frequent emotional malady of young women in the 19th century, may have been related to the prevailing zeitgeist typified by oppressive attitudes and behaviors toward women.
Considerable variability exists in the course of BPD. The impairment from the disorder and the rise of suicide are greatest in the young adult years and gradually wane with advancing years (APA, 2000; Rubinow and Schmidt, 1996). Paris and Zweig-Frank (200) studied the outcomes of patients with BPD who were followed for 27 years and found that they “continue to improve in later middle age.” The cohort experienced a reduction in BPD symptoms as well as a reduction in major depression and substance abuse.
Borderline syndrome is often characterized by dramatic flare-ups. Symptoms often partially mimic other DSM-IV Axis 1 conditions that are usually considered as comorbid (Nurnberg et al., 1991). These other conditions may include depression, anxiety, panic disorder, cyclothymia, obsessive-compulsive disorder, somatoform disorder or schizophreniform psychosis (Bolton and Gunerson, 1996).
The clinical symptoms are triggered periodically by seemingly innocuous events heralding yet another new crisis. The expression of the symptoms has been attributed variously to core traits such as impulsiveness, affective instability and excessive compulsivity (Paris, 1994).
In reality, the symptoms involve all higher mental functions including cognitive and emotional functions (Paris, 1994) and those relating to the self (Pinto et al., 1996; Richards, 1989; Sandell, 1989). Additionally, the symptoms display a characteristic, often extreme, short-lived oscillation between antithetical ways of thinking, feeling and behaving (Pediaditakis, 1998; 1992). For example, severe depression and demoralization are followed often in minutes or hours by emotional effervescence and exuberance bordering on hypomania (Widiger and Weissman, 1991). Explosive temper and vituperative behavior alternate rapidly with the expression of over-restraint, over-politeness, exaggerated reasonableness and expression of prostration to the degree of obsequiousness. ironically, clinicians may misperceive this reasonableness as an indicator that the patient is recovering, since the behavior is consonant with social norms. Unfortunately, this reasonable behavior merely represents with other extreme of the oscillation and is short-lived, leaving the clinician bewildered by the change (Levine et al., 1997).
Frequently, when patients display an escalating uncontrollable rage, they may also briefly develop loose associations and frank paranoia (Pediaditakis, 1998). Heightened obsessiveness, rumination and compulsivity are followed by an outright personal slovenliness in the patient’s tasks and habits. Dissociated feelings, deja vu phenomena and self-doubt alternate with heightened clarity and focusing (an over-looked phenomenon). Sexual promiscuity alternates with strict celibacy. Binge-eating is often followed by willful fasting. Bouts of alcohol use and drug abuse are followed by total abstinence. intense idealization of important people is followed by debasement of those same people (splitting.) Periodic fearfulness about personal safety, coupled with a heightened sense of vulnerability, alternate with remarkable daring, bordering on recklessness.
There is a different emphasis on the expression of these symptoms in each crisis or flare-up. Symptom combinations also vary from patient to patient, depending on the individual’s particular mix of temperamental components that render them vulnerable to the development of BPD.
In the medical literature, these extreme pendulum-like phenomena are described by such terms as deregulation (Svrakic et al., 1991) or flawed emotional organization. These terms, being somewhat tautological, are not particularly useful in identifying possible mechanisms or causes.
There is an existing (albeit overlooked) mode of brain function that normally insures a coordinated smoothness and synchronism across the expression of the higher mental functions. But in patients with borderline syndrome, there is a structural abnormality that renders the brain vulnerable to a periodic loss of this synchronism. What periodically emerges is a pathological phase of rude “either-or-ness,” expressions of antithetical extremes and an overall intolerance of ambiguity (entertainment) – a kind of a “psychic-parkinsonism” (Pediatitakis, 1992).
Such oscillatory phenomena also are common in the clinical expressions of other major disorders, although not in such a stark form (Pediaditakis, 1998). This oscillatory nature in the expression of antithetical substitutes has been described in the literature as splitting, cyclothymia, yearning for intimacy and fear of aloneness versus fear of engulfment. Even though these descriptions imply oscillations, they tend to obscure the collective significance of these phenomena.
The role of Temperament. Empirical observations and recent studies show that those at risk belong at birth to a particular type of temperament that is an extreme variance of the normally occurring temperament types (Clarkin et al., 1993; Paris, 1994; Soldz et al., 1993; Trull, 1992). This temperament is characterized by the presence of a heightened intensity/reactivity that appears to trigger periodic flare-ups. Like a kindling flame, this intensity initiates escalating, crescendo-like phenomena (i.e., escalating vituperativeness, rage, depression and anxiety). For this reason, a more descriptive term for the borderline syndrome could be disorganizing hyperintensity disorder. This change would allow us to avoid the somewhat pejorative and awkward term of borderline personality disorder. This change would allow us to avoid the somewhat pejorative and awkward term of borderline personality disorder (borderline to what?) and focus instead on the crucial triggering factor of hyperintensity, with its possible therapeutic implications.
Patients with borderline syndrome also are temperamentally inner-oriented, uneasy in interpersonal interactions and aloof, experiencing notable difficulty with emotional connectedness; however, they often learn to affect a forced cordiality and sociability. This unconnectedness is perceived by these patients as “aloneness from within,” and felt as a “dread beyond telling.” Such feelings are fought with frantic thrill – and novelty-seeking activity, as if the patient is trying to cancel out the loneliness (Pediaditakis, 1991), or with frequent, intense, short-lived relationships based on idealizations. Patients also are preoccupied with themselves and have an overriding need to safeguard their own autonomy (Clarkin et al., 1993; Soldz et al., 1993; Trul, 1992).
Conversely, these sufferers tend to be conceptual thinkers, perceptive and adept at pattern recognition. While these qualities may help patients arrive at novel approaches to factual problems, when these same qualities are misapplied, patients may become paranoid. These patients also have a heightened yet oscillating compulsivity. Sociobiological attributes such as empathy, sociability and altruism are only weakly represented in these patients.
Early Environment Factors. In young people who are at risk, the possible development of BPD depends on the confluence of certain early events within the family (Paris, 1994; Paris and Frank, 1989).
These events may include a mismatch of temperaments between the patient and the parent of the same gender. As is often the case of daughters who suffer from BPD, the mother’s temperament may be antithetical to that of the daughter. For example, the daughter is inner-directed, whereas her mother is sociable. The daughter is intense, while her mother is placid and laid-back. These differences may prevent the fulfillment of the daughter’s critical need to identify with her mother. The mother is psychologically unavailable as a role model, and the daughter may disdain and vilify her (Paris and Frank, 1989; Zanarini et al., 1997). The mis-matching contributes to the patient’s lack of inner certainty as a person, possibly contributing to the disturbance of the self (Gunderson, 1996).
In some instances, a nurturing mother will vainly attempt to help her daughter. The mother’s efforts are then labeled as over-involvement and often erroneously considered as contributory factors for her daughter’s condition (Goldman et al., 1993).
While I have consistently observed this mismatching in the patients with BPD that I treat, the clinical literature has missed this phenomenon, possibly because we usually fail to consider the role of temperament in clinical studies. A study with actual measurements of the patient’s, the mother’s and the father’s temperaments could verify or invalidate this empirically observed phenomenon.
Women with BPD often share their father’s temperament. Such patients tend to be beguiling, appealing and charming, yet, at a moment’s notice, they can oscillate from being appealing waifs to insufferable vixens, becoming cold, vituperative and demanding. These characteristics often become important factors in the development of countertransference phenomena in the therapeutic team (Gunderson, 1996; Pediaditakis, 1998).
During their formative years, patients with BPD in an unstructured environment are often overvalued and even indulged children. They end up unschooled in fortitude and perseverance. They also have an exaggerated sense of personal expectation for future, unspecified, great achievements, with the resultant periodic demoralization stemming from the underlying belief that “Unless I am the greatest, I am nobody.”
Alternatively, they may have a broken or disorganized family, marked by psychopathology and abuse (Goldman et al., 1993; Herman et al., 1989). Unfortunately, patients with BPD from a low socioeconomic background, especially males, also frequently break the law, resulting in their imprisonment (i.e., criminalization of their condition).
In either the unstructured environment or the broken/disorganized family, individuals at risk for BPD are denied the structure necessary to develop a strong sense of self with the presence of boundaries, restraint, fortitude and discipline.
As used here, structure means the presence of implied or explicit rules regarding mutuality of obligations, respect and assistance (a sense of belonging) between family members; constraints; firmness; clarity of roles; perseverance; and persistence of effort; as well as consistency and constancy in family relationships and life.
Recently, researchers have identified particular combinations of personality traits among individuals with borderline and other personality disorders (Livesley et al., 1998). It is the interaction of these traits and the possible adverse influence of the early environmental events mentioned above that serves as a matrix for the development of the disorder.
Another contributing factor may be the current social zeitgeist, which places justified and overdue value on women’s autonomy and independence. Unfortunately, young women susceptible to BPD typically misinterpret cultural guidelines. By temperament, they feel tense and uneasy in social interactions, intimacies and friendships. They easily perceive calls for female autonomy as instructions to deflect the underlying, natural need and desire for intimacy and bonding. In this way, they are further prevented from developing a normal, mutual relative interdependency with an appropriate mate. This conflict later contributes to the expression of yet another oscillatory phenomenon – the fear of abandonment followed by the fear of engulfment (Melges and Swartz, 1989).
Additionally, the advent of women’s freedom from oppressive and stifling shackles came with the abandonment or decrease of traditional supports (e.g., financial and emotional safety nets) once deemed necessary for women’s well-being. While the lack of such supports may be no problem for most women, it may be a problem for vulnerable candidates of BPD.
The therapeutic challenges of BPD are daunting. Its mercurial expressions tax our resources as humans and can induce counter-oscillatory phenomena in the therapist (e.g., recoil or moral indignation versus over-solicitousness or an intense desire to rescue the patient).
Consequently, several approaches are needed. The clinician should consider obtaining a second opinion. It is also important to assist the patient initially with simple demythologizing explanations such as, “Your intensity takes the best out of you.” The clinician must resist accommodating the felt ineptitude of the patient (entrapment in self-defeat). Both pedagogic and didactic approaches are useful for teaching the patient temperament management skills.
Some specific psychological interventions have been found efficacious for treating BPD. These include dialectical behavior therapy (DTB), psychoanalytic psychotherapy, group psychotherapy, family therapy and supportive psychotherapy. However, randomized controlled trials are rare.
Teaching patients ways to manage their temperaments can involve Marsha M. Linehan, Ph.D.’s, dialectical behavior therapy (DBT). It incorporates behavior therapy, Zen and dialectical philosophy, and it encourages patients with BPD to accept negative affects without engaging in self-destructive or maladaptive behaviors. Behavioral techniques include skills training (e.g., distress tolerance and emotion regulation); contingency management; cognitive modification (e.g., addressing faulty beliefs); and exposure-based strategies for addressing fear, anger, guilt and shame (Robins et al., 2001).
In randomized clinical trial, patients treated with DBT compared to a treatment-as-usual (TAU) control group, had significantly fewer parasuicidal episodes, a lower treatment dropout rate and fewer psychiatric inpatient days. Those gains were retained for at least six months (Linehan et al., 1991, as cited in Linehan et al., 1993).
Recently, independent investigators compared the efficacy of DBT with TAU in a U.S. Department of Veteran’s Affairs clinic. They treated 20 women veterans diagnosed with BPD and found that the DBT-treated patients had significantly greater reductions in suicidal ideation, hopelessness, depression and anger expression compared to the TAU group (Koons, in press, as cited in Robins et al., 2001.)
Recent empirical research also supports the usefulness and cost-effectiveness of psychodynamic psychotherapy for BPD (Gabbard, 2001). For example, Bateman and Fonagy (1999) compared 19 patients with BPD who were treated with psychoanalytically oriented partial hospitalization to 10 BPD patients treated with standard psychiatric care. Patients treated with partial hospitalization for 18 months showed significant improvement on both symptomatic and clinical measures.
Because patients with BPD, by the very nature of their condition, are skittish about taking medications and often noncompliant, clinicians need to provide them with detailed explanations for all medications. Clinicians also should consider initially prescribing very small amounts of antiparaphora medications (Gk., parafora means emotional turmoil and over-intensity).
Drugs in each medication class have some potential utility and are used against specific symptoms in most patients with BPD. In a survey to determine which medications were preferred by psychiatrists for treating BPD, Silk et al. (2001) found that about half of 85 respondents would use a selective serotonin reuptake inhibitor as their first-choice medication; 20%, a mood stabilizer; 20%, a non-SSRI antidepressant; and 10% would choose an antipsychotic.
Since BPD symptoms span periodically the entire range of brain function, no single pharmacotherapy should be expected to work for all manifestations of the illness. Polypharmacy is usually necessary, and clinicians should introduce each medication separately, starting at low doses.
Because of their serotonergic-enhancing properties, SSRIs have proved efficacious in reducing some of the impulsive, aggressive and self-destructive behaviors that accompany BPD (Schatzberg, 2000). Anticonvulsants have been found useful in treating specific symptoms as well. For example, Hollander et al. (2001), in a double-blind, placebo-controlled trial, found that divalproex sodium (Depakote) was more effective than placebo for global symptomatology, level of functioning, aggression and depression in patients with BPD.
In a double-blind study, Zanarini and Frankenburg (2001) compared the efficacy of the atypical antipsychotic olanzapine (Zyprexa) with palcebo in females with BPD. They concluded that olanzapine appeared to be safe and effective, significantly affecting all four core areas of borderline psychopathology (i.e., affect, cognition, impulsivitiy and interpersonal relationships). Weight gain was modest in the olanzapine-treated group, and no serious movement disorders were noted.
The research community could further assist clinicians by conducting studies on the particular termperament of the patient; the mismatch of temperaments between patients and same gender parent; the role of the weak or absent structure early on in life; the disorganizing over-intensity/reactivity; the role of the current zeitgeist; and the oscillatory format of the clinical expressions of the disorder.