PERSONALITY DISORDERS

(DSM-IV TR, APA, 2000)

Borderline personality disorder is characterised by intense fluctuations in mood, self-image and interpersonal relationships. Borderline personalities are impulsive and unpredictable with a chronic feeling of emptiness and an intense fear of abandonment. These characteristics begin in early adulthood and are present in a variety of contexts (DSM-IV, 1995)

The intense instability is manifest in drastic mood labiality and anger, borderline personalities may be quite friendly one moment and considerably hostile the next (Sue, Sue & Sue, 2000). The instability also manifests in erratic, self-destructive behaviours such as shoplifting, binge-eating, gambling sprees and excessive sexual activity. (Carson et al, 1992)

Suicidal attempts are frequent, particularly attempts that are manipulative in nature. Self-mutilation is one of the most discriminating diagnostic criteria for borderline personality disorder (Carson et al, 1992).

Borderline personality disorder may exhibit stress-induced psychotic features, which are usually transient, but it is notable that they are ego-dystonic in that, unlike the psychotic disorders, borderline personalities recognise their hallucinations as unreal, unacceptable and distressful (Spitzer et al, 1981, cited in Sue, Sue & Sue, 2000).

Mood changes, unstable relationships, self-identity problems and the other characteristics associated with borderline personality disorder may display to some extent in many people. This makes diagnosis difficult

Although no single feature defines borderline personality disorder, its essence is the fickleness of behaviours and the mood labiality (Sue, Sue & Sue, 2000). “Borderline personality disorder refers to a level of personality organisation (i.e. one that is fairly immature) that cuts across categorical disorders, rather than a discrete syndrome” (Morey, 1993, p156)

Most importantly in order to qualify for a diagnosis of a personality disorder the following factors must be considered:

1. Current as well as long tem functioning must be taken into account
2. Not limited to current episodes of illness
3. Notably impaired social or occupational function which cause significant distress

Associated Features and Disorders

The personality disorders are recognised as having significant associations with various psychopathologies. More often than not, a multiple personality diagnosis seems to be the rule of thumb in that individuals meet the criteria for more than one personality disorders. Of the personality disorders, borderline personality disorder specifically tends to co-occur with other personality disorders, whether this is because of the high prevalence of borderline personality disorder or a function of the nature of the disorder remains unclear. (Morey, 1993)

Borderline personality disorder is a personality disorder with noticeable affective features and conspicuous impulsivity. Empirical results have shown associations with similar Axis 1 disorders such as affective disorders and substance abuse respectively. The high rate of suicidal ideation in borderline personality disorder correlates with high rates of suicidal behaviour (Morey, 1993) with approximately 6% succeeding in their attempts (Perry, 1993, M.H Stone, 1989, both cited in Barlow & Durand, 2002)

The concept of spectrum personality disorder suggests that personality disorders are an early form of affective disorder (Akiskal, 1985 cited in Klein, 1993) or a defence against depression.

Gender bias

More women are diagnosed with borderline personality disorder with a gender ratio of 3:1 (Barlow & Durand, 2002). It is unclear whether these disparities show differences between men and women in certain genetic predispositions and/or sociocultural experiences, or whether they indicate a bias on the part of the diagnostician. While this remains a controversial issue, it is important to note that the observation of borderline personality disorder more frequently in women does not necessarily indicate a bias albeit Westen (1997, cited in Barlow & Durand, 2002) found than clinicians tend to use more subjective impressions to diagnose Axis II personality disorders and use the DSM criteria more diligently for Axis 1 disorders.

Axis I vs Axis II disorders

This writer is interested in the prevalence of misdiagnosis of Borderline Personality Disorder. It seems that there is a considerable comorbidity and overlap of Axis 1 and Axis II diagnoses.

“It is generally accepted that Axis I symptoms may distort the presentation and assessment of traits.” (Klein, 1993, p. 25) and it is suggested that a personality disorder may be an early or attenuated form of an Axis I disorder (Klein, 1993) or alternatively a defence against an Axis I disorder.

Personality disorders differ from most Axis I disorders in that they lack a clear boundary with normality (Tyrer & Ferguson, 1988, cited in Paris, 1993).

It is important to consider longitudinal functional and not just take a cross sectional account of current functioning. For example major depressives may display many of the features of borderline personality disorder just after a suicidal attempt and a misdiagnosis may be made.

Using the edifice of the possible link to abuse in borderline patients, Guldersand & Sabo (1993, cited in Barlow & Durand, 2002) argue that borderline personality disorder is similar to Post Traumatic Stress Disorder (PTSD) and that the diagnosis of borderline personality is simply a case of PTSD amongst women where the focus is on the victimisation of women rather than mental illness. Difficulties in mood regulation, impulse control and interpersonal relationships are also the hallmarks of PTSD. This lends support to the possibility that BPD may be caused by early trauma in some individuals. Not all cases of borderline personality, however, not all borderline personality disorders resemble PTSD.

“Borderline personality disorder refers to a level of personality organisation (i.e. one that is fairly immature) that cuts across categorical disorders, rather than a discrete syndrome” (Morey, 1993, p156)

Cross Cultural Validity

Definitions of “normal” personality may differ from culture to culture. Behaviours that are considered deviant in one society may be considered acceptable in another ethnic group. What is considered deviant may also change over time. For example one of the classifications of borderline personality disorder in DSM is excessive sexual activity defined as self-damaging. Susanna Kaysen, whose life story was told in Girl Interrupted, was diagnosed with borderline personality disorder because amongst other things she was sexually active, which at the time was considered socially unacceptable and self-damaging. The same behaviour in the 21st century would not be considered deviant and in some sub-cultures would be considered as abnormal not to be sexually active.

Diagnosis is always culturally specific. Marcie Kaplan (1983, cited in Barlow & Durand, 2002) suggests a Diagnosis of “Independent” Personality Disorder, which is indicated by workaholic behaviour, and avoidance of emotional issues at the expense of ones career. This tongue-in-cheek rejoinder to the psychiatric fraternity highlights the cultural validity and gender bias evident in several of the diagnoses of personality disorder. Independent personality disorder would clearly be what is considered “normal” in health ambitious people, but would clearly describe more males than females.

Prognosis and Treatment

Most people with personality disorders function adequately in spite of their adjustment problems and do not seek help because they do not believe they have a problem. Borderline personalities are more likely to seek treatment as a result of depression or other pathologies like substance abuse.

Certain types of disorders such a borderline personality disorder are notoriously difficult to treat and borderlines are more likely that others to deteriorate in treatments and be worse off than had therapy not been undertaken (Carson & Butcher, 1992). In the interest of ethics the clinician should take this into consideration.

The course is variable, with chronic instability in early adulthood being the most common pattern. Serious affective disorders and lack of impulse control are prevalent with high levels of use of health and mental health resources.  Many borderline patients improve in their thirties and develop more stability in their relationships and career. (DSM IV, 1995)

AETIOLOGY

The Biopsychosocial model is particularly appropriate to the personality disorders in that the available empirical data maintains that only a combination of biological, psychological and social risk factors is a sufficient combination for the development of these disorders (Paris, 1993). Borderline personality disorder would then be understood as a heritable biological predisposition manifest in personality traits, which are precipitated and amplified by psychosocial variables.

The diathesis stress response model explains why an inherited vulnerability may only sometimes precipitate a personality disorder. It is only in combination with psychosocial stressors that a genetic tendency may bring about a borderline personality.

BIOLOGICAL FACTORS

Gender

As has already been mentioned more women are diagnosed with borderline personality disorder than men.

Families and Borderline Personality Disorder

Family studies indicate that borderline personality disorder is more prevalent in families with the disorder as well as families with mood disorders (Wideger & Trull, 1993, cited in Barlow & Durand, 2002). There is also an increased familial risk of substance abuse, anti-social personality and mood disorders (DSM-IV, 1995)

Traits and Temperament

Biological predispositions are reflected in heritable personality traits, which are precipitated or amplified by psychosocial factors (Paris, 1993)

“Traits are complex dispositions that involve both behavioural and cognitive factors and reflect an important degree of environmental input” (Paris, 1993, p. 256).

Biological Markers

There is some evidence that impulsive personality traits are links with levels of serotonin activity in the brain (Siever & Davis, 1991; cited in Paris, 1993)

A psychobiological model relates personality traits and disorders to variation in neurotransmitter interactions.

Biological factors alone do not seem to account for the development of personality disorders. Most likely a biopsychosocial model is the best explanation in that biological factors are probably necessary, but not sufficient conditions for the development of personality disorders. Biological factors may also be limiting factors for the type of disorder that can develop in any individual (Paris, 1993)

PSYCHOLOGICAL RISK FACTORS

Interpersonal Theory:

Interpersonal theory considers the development and maintenance of borderline personality disorder. The role of early childhood experience and social learning factor in the development of personality traits. The individual’s current intimate and social relationships provide a context in which the disorder develops and is maintained. Psychosocial treatment in the form of the therapeutic relationship provides a medium for change.

The interpersonal approach is a systemic one which is circular in its reasoning and would explain predisposing factors such as early childhood experience and then precipitating factors such as psychosocial stressors which cause and maintain the disorder.

Early Childhood Experience

Early separation and losses have been reported in the histories of borderline personalities (Paris, 1993). The long tem effects of separations and loss in early childhood seem to depend on interactions with other factors.

Many borderline personalities remember the prevalence of malevolent others in their childhood – that is people who were hostile or violent. (Nigg et al, 1992, cited in Sue et al, 2000). Benjamin & Wonderlich (1994) found that borderline personalities viewed their mothers and others in their environment as more hostile that a comparable group with affective disorders.

The few empirical studies that exist on borderline personality disorder have found that borderline personalities have a history of chaotic family environment and physical and sexual abuse (Clarin, Marziali & Munroe-Blum, 1991, cited in Sue et al, 2000)

Zanarini (1997 cited in Barlow & Durand, 2002) found 91% of borderline personalities reported a history of abuse and 92% reported neglect prior to the age of 18.

Childhood sexual and physical abuse is not specific to a diagnosis of borderline personality disorder and is prevalent in many Axis II disorders. We cannot confirm that childhood abuse causes borderline personality disorder, however, it may be a significant predisposing factor in some cases. This might also explain why borderline personality disorder is more prevalent in women: girls are two or three times more likely to be sexually abused than boys.

Psychodynamic Perspective

The neo-Freudian and object-relations proponent Otto Kernberg, (1976 cited in Sue et al, 2000, cited in Carson et al, 1992) believed that the borderline personality is predominantly unstable, especially in interpersonal relationships and is fundamentally unable to achieve a full and stable self identity. He attributed this to an inability to integrate and reconcile pathological internalised objects. He proposed the concept of object-splitting – that borderline personalities perceive others as all good or all bad at any one time – this split results in the emotional fluctuations towards others

Perry (1988, cited in Morey, 1993) showed that borderline personality disorder is associated with the use of immature defence mechanisms.

Social Learning Theory

Bandura’s social learning theory (1977, cited in Paris, 1993) explains the development of personality traits in children through modelling or the direct reinforcement of their parents. Social learning theory is limited however as indicated by the differences in personality between children raised by the same family.

Masterson (1981, cited in Sue et al, 2000) believes that borderline personalities lack purposefulness and directedness in long tem goals because of a lack of emotional investment in the self.

Milon (cited in Sue et al, 2000) suggest that borderline personality is caused by a faulty self-identity, which affects the development of consistent goal directed behaviour. This results emotional liability and coping difficulties with life in general. A conflict then ensure between the need to be self-sufficient and the need to depend on others.

Sable (1997, cited in Sue et al, 2000) describes the need for attachment and intimacy which conflicts with a fear of commitment as a result of early traumatic attachment experiences rather than a faulty self-identity.

Cognitive Behavioural Model

The study of cognitive factors in Borderline personality disorder is in its infancy. Do borderline personalities process information differently from others and does this contribute to their maladjustment?

Beck (1990, cited in Sue et al, 2000) maintains this is the case and suggests that a person basic assumptions and thoughts play a role in influencing perceptions, interpretations, behaviour and emotional responses. The borderline personality lives with three assumptions:

1. The world is dangerous and malevolent
2. I am powerless and vulnerable
3. I am inherently unacceptable

(Ibid)

These three beliefs engender fear, vigilance and defensiveness, which is manifest in intense interpersonal relationships.

“Many forms of psychopathology can be thought of as a form of experiential avoidance … As experiential avoidance takes hold, more stress and arousal is likely, which in turn occasions more evaluative verbal comparisons, and more self-focused avoidance strategies” (Hayes & Wilson, 2003, p. 127)

Linehan (1987, cited in Sue et al, 2000) posits that dysfunctional emotional regulation and fluctuating emotions are at the core of the borderline personality disorder. Dialectical Behaviour therapy is a promising treatment for borderline personality disorder, which is based on a dialectical worldview, which defines reality consisting of opposing forces. The central dialectic is the relationship between acceptance and change. Borderline personalities are encouraged to accept themselves, their histories and their current status quo as they are, but to concomitantly strive to change their behaviours and environments in order to bring about a more self-actualised life. This is practiced with mindfulness, which Linehan describes as “observing, describing, participating non-judgementally, in the present moment, effectively” (Dimidjian & Linehan, 2003, p. 170)

Mindfulness-based Cognitive Therapy (MBCT, Teasdale, Segal and Williams, 1995, cited in Baer, 2003) and Acceptance and Commitment Therapy (ACT; Hayes & Wilson, 2003) also incorporate mindfulness in their approaches.

“Cognitive diffusion … helps pierce the illusion of language” (Hayes, 2002, p. 104) by drawing attention to the process of relational activity and not only the products. This is similar to exposure with the focus being on the process, exposure alone may exacerbate the cognitive entanglement.

Westen (1991, cited in Sue et al, 2000) combines the theories of Beck and Linehan and defines two core aspects of the borderline personality: difficulties in regulation emotions and intense interpersonal relationships. These two factors are the result of distorted and inaccurate attributions of the behaviour and attitudes of others. Westen’s CBT challenges the way the borderline personality thinks about and approaches interpersonal interactions.

Any childhood experience that is sufficiently negative may influence trait-related behaviours to dysfunctional levels (Paris, 1993). Thus psychological risk factors can only be considered in interaction with biological vulnerabilities.

SOCIAL RISK FACTORS

Borderline personality disorder seems to be increasing because our society makes it difficult for people to maintain stable relationships and a sense of identity (Sue, Sue & Sue, 2000).

Social disintegration (Leighton, Harding & Macklin, 1963, cited in Paris, 1993), which includes family disruption, weak community links, poverty, secularisation, migration and rapid social change, makes it difficult to develop the close community networks and family structure prevalent in pre-industrial times, and borderline personality disorder is indicated in these communities. Adult and child immigrants also manifest a low anxiety threshold, self-identity issues, emptiness and fear of abandonment (Laxenaire, Ganne-Vevonec & Strife, 1982; Skhiri, Annabi, Bi & Allani, 1982; both cited in Barlow & Durand, 2002). This lends further support to the theory that early trauma may lead to borderline personality disorder in some people.

Social risk factors may interact with biological and psychological vulnerabilities to bring about borderline personality disorder in that personality traits that are marginally adaptive under stable social climates may become maladaptive when exposed to rapid social change (Paris, 1993). For example, traits of impulsivity may be exacerbated by a loss of social role structures, which provide a buffer against impulsive actions.

SOCIAL BUFFERS

Inevitably the question that comes to mind is why some people are susceptible to personality disorders and others, when exposed to the same stressors, are not.

A supportive social environment would help with the affective instability in borderline patients and act as a buffer against the effects of chaotic families. A strong sense of social identity and roles would provide a buffer against the impulsivity of borderline personality disorder.

Studies of “resilient children” found that where alternative attachments and support structures were available, personality disorders did not manifest despite highly dysfunctional familial patterns (Anthony & Cohler, 1987; Kaufman, Grunebaum, Cohler & Gamor, 1979; cited in Paris, 1993).

Thus the presence or absence of attachments to the wider social network could be a factor that determines whether personality traits develop in to disorders.

AN INTEGRATIVE APPROACH

It is important to note that various biological, psychological and social factors may contribute to the development of borderline personality disorder and other personality disorders, the biopsychosocial model seems to proffer a more integrative and systemic understanding of the development and maintenance of this disorder.

The biopsychosocial model proposes multiple causal factors and would explain why individual risk factors are not strongly associated with specific disorders. The presence of biological variability on its own is not sufficient to bring about borderline personality disorder. It does explain variance in personality, but it only determines the specificity of a personality disorder. Psychological and social risk factors and much stronger determinants of whether a predisposition develops into a disorder (Paris, 1993).

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REFERENCE LIST:

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