The notion of personality refers to a set of rather stable characteristics that guide someone’s behavior and thinking. Personality disorders represent patterns of dysfunctional behavior that are stable and have been present in the individual since very young age. These patterns:
- Go against many social and cultural expectations
- Are relatively unchangeable and displayed over a number of different contexts even when they are deemed inappropriate
- Lead to issues with the person’s relationships, work, overall functioning, and other important areas in life
Personality disorders are considered to be severe types of psychopathology, and individuals with these disorders experience marked levels of dysfunctional issues in their lives, even though many individuals with personality disorders place the blame on others and not on themselves. One of the most dysfunctional personality disorders is borderline personality disorder.
Borderline Personality Disorder
Currently, the American Psychiatric Association recognizes 10 formal personality disorders that are arranged in three different groups. The groups are defined by the primary issue characterized by the disorder. Borderline personality disorder (BPD) is classified as a personality disorder where the primary issue is one with dramatic and/or eccentric emotional responses. Individuals with BPD often display severe and erratic patterns of behavior. The tag borderline was originally used in the description of individuals with this disorder because they often appear to be on the boundary of psychotic behavior (being unable to distinguish reality) and normality.
There are nine formal diagnostic criteria that are used to diagnose BPD. A formal diagnosis of the personality disorder requires that the person display five or more of the nine symptoms consistently. Only needing to satisfy five of nine potential symptoms can result in many different presentations of BPD. As will be seen later, some researchers have tried to define different subtypes of BPD because of the variability in the disorder.
The formal diagnostic criteria will not be presented here, but some general descriptors of BPD include:
- People display alterations in the way they view others. These viewpoints are typically extreme. Most often, individuals with BPD will idolize a person or engage in extreme devaluation of a person (e.g., total discussed in hatred). These viewpoints of others can change from one end of the spectrum to the other very quickly based on the other person’s behavior. People with BPD often have no “middle ground” for significant people in their lives. They rate them at one extreme end of idolization or loathing, or the other.
- People with BPD have extremely unstable self-image and longstanding feelings of emotional emptiness and loneliness. People with BPD will engage in extreme behaviors to avoid feeling alone or abandoned by others even if there is no basis for feeling this way.
- People with BPD demonstrate extremely unstable emotions and frequent emotional outbursts. They have difficulty controlling their emotions, particularly anger. These individuals are well known for having chronic outbursts of anger. People with BPD will often engage in threats, gestures, or actual suicidal behaviors, or they will engage in self-injurious behaviors such as self-mutilation (e.g., burning oneself, cutting oneself, etc.).
- People with BPD also have chronic issues with paranoia and/or dissociation. Dissociation represents the feelings of being detached from reality, one’s body, or having issues with remembering things. In BPD, memory issues are often associated with extreme emotional states, such as anger outbursts.
- People with BPD are often extremely impulsive. This impulsivity occurs in more than one aspect of the person’s life and leads to potentially dangerous or self-injurious behaviors, such as severe substance abuse, binge eating, self-destructive behaviors like cutting, etc.
Because of the potential for individuals diagnosed with BPD to have entirely different presentations, researchers have tried to identify different subtypes of BPD. The late psychologist Theodore Millon suggested that there were four different BPD subtypes:
- Impulsive BPD: The primary issue with this subtype is impulse control. This subtype is prone to engaging in thrill-seeking, self-mutilation, and potential suicide. Due to a lack of impulse control, this subtype also displays extreme emotional swings.
- Petulant BPD: These individuals often fluctuate between severe feelings of being unworthy and explosive outbursts of anger. They are driven by chronic fears of being abandoned or rejected, and display severe jealousy, attempts to control others, anxiety, anger, and possessiveness. This leads to issues with substance abuse.
- Discouraged BPD: This subtype is very passive and reliant, and presents as being very clingy and dependent on others. They have anger issues, but the anger is often focused at themselves, and there is a high rate of self-mutilation and suicidal gestures or attempts.
- Self-destructive BPD: This subtype also has a chronic need for attention but harbors intense feelings of self-hatred. This leads to a number of self-destructive behaviors, including substance abuse and engaging in risky activities, such as having multiple unprotected sexual encounters, thrill-seeking, etc.
Because of the multiple issues that are associated with BPD, the diagnosis rarely occurs in isolation. People with BPD are often diagnosed with other types of psychological or psychiatric disorders or with substance use disorders.
BPD and Other Disorders
It is not uncommon for individuals with BPD to have numerous diagnoses. The most common comorbid (co-occurring) disorders are:
- Bipolar disorder
- Anxiety disorders (e.g., phobias or panic disorder)
- Post-traumatic stress disorder
- Other personality disorders
- Substance use disorders.
Individuals with BPD often experience issues with relationships and their own emotional instability. Engaging in the use of alcohol or drugs often represents a substitution for relationships that allows people with BPD to feel a sense of control over themselves and others.
Those with BPD are especially prone to abusing alcohol or prescription medications. Alcohol is a central nervous system depressant, and this helps to deaden the emotional stability associated with BPD. The tendency to abuse prescription medications is probably related to a propensity for individuals who have not been formally diagnosed with BPD to be prescribed medications for issues with pain, weight loss, or even anxiety. However, it should be noted that individuals with BPD are prone to any form of substance abuse due to the high rates of anger, dissatisfaction, feelings of loneliness, and issues with emotional instability.
Comorbidity refers to being diagnosed with more than one illness or disorder at the same time. As mentioned above, BPD is typically comorbid with a number of different conditions. Having a dual diagnosis, a psychological/psychiatric disorder and a substance use disorder, is a form of comorbidity. Estimates of BPD and comorbid substance use disorders range up to 50 percent of individuals diagnosed with BPD, and in some studies, this relationship is considered to be even higher. This type of dual diagnosis presents an extremely complicated treatment issue.
Treatment Issues for BPD and Co-Occurring Substance Use Disorders
BPD is a condition that is notoriously difficult to manage. Because these individuals often idolize their treatment team at first and then, when issues occur that are not to their liking, demonized them, the therapeutic process becomes extremely unstable. In addition, individuals diagnosed with personality disorders do not visualize the nature of the problems as being issues with them, but instead see them as being issues with everyone around them. Thus, the combination of unstable emotions, issues with rejection, unwillingness to engage in treatment, and any co-occurring substance abuse results in extremely difficult situation.
A specific form of therapy known as Dialectical Behavior Therapy (DBT) was developed specifically to deal with the types of emotional issues displayed in individuals with BPD. DBT has become the recognized frontline treatment approach for individuals with BPD. It involves a number of different therapeutic approaches, including individual therapy, group therapy, psychiatric involvement with medications, involvement in substance abuse groups such as 12-Step groups, and other forms of intervention like case management, vocational counseling, and rehabilitation counselors. People diagnosed with BPD are very adept at their pathology and will try to play different counselors/therapists against one another; however, the treatment team will typically stay focused and communicate with one another regarding therapy progress and issues to address.
- Treatment typically consists of individual therapy sessions where the therapist and client work on issues with emotional instability, issues with abandonment, and other relevant issues to the case. Individual sessions typically meet on a weekly basis.
- Group sessions that are psychoeducational in nature and teach the client’s coping skills are often used. These sets of the group sessions are structured to meet once a week and typically run 24-28 weeks and then are repeated.
- Psychiatrists typically provide medically assisted treatment. There is no specific medication to treat BPD; however, medications for issues with anxiety, depression, and other related issues are often used.
- Substance abuse counselors in support groups directly address the substance abuse issue. These issues are also addressed in individual and group therapy.
- Other supports, such as vocational counseling or rehabilitation counseling, are scheduled as needed.
Though this targeted approach to treating someone diagnosed with BPD and a comorbid substance use disorder is challenging, recovery is possible. Because these issues are all intermingled in the individual’s psychopathology, substance abuse must be treated concurrently with other issues, such as a comorbid diagnosis of BPD. It is counterproductive to try to address one issue and ignore the other. This presents a more complex and lengthier treatment program for these individuals; however, many can realize an optimum level of functioning as a result of comprehensive treatment.