Lexicon of Madness -- Borderline Personality Disorder

Borderline Personality Disorder: Arguably the most severe of the personality disorders. As originally conceived, people with this characterological disorder stand on the border between neurosis and psychosis. In the past, some have called the condition "ambulatory schizophrenia." Their personalities are marked by instability -- unstable mood/affect (e.g., "happy one minute and in a rage the next"); unstable relationships (e.g., "they think you are perfect one day and the next day you are the devil"); and, unstable sense of identity (e.g., "they can't maintain a stable sense of who they are, or whether they are completely worthless or not"). Borderline Personality Disorder (BDL) is found in about 2% of the general population and is twice as common in women as in men. There are high rates of comorbidity, especially substance abuse disorders and major depression. Many people with BDL are often misdiagnosed with Bipolar Disorder. BDLs have chaotic lives and their relationships are tempestuous, to say the least. Because they are both hostile and dependent, their behaviors drive people away and this results in panic over being "abandoned." They see people as either "all good" or "all bad" (i.e., they engage in "splitting"). It has been proposed that BDLs project the despised part of themselves onto other people (i.e., "projective identification"), which is why they can unload such intense anger onto those around them. Until relatively recently, self-harming behavior (e.g., cutting, or repeated low-lethality suicidal behaviors such as wrist-slashing) was almost pathognomic for BDL. Unfortunately, these behaviors have since spread more generally. Under stress, BDLs may experience psychotic symptoms (e.g., delusional beliefs, or hearing someone calling their name). Often, they simply feel empty inside. They cannot tolerate being alone, and will behave promisciously to attain superficial intimacy. They will also take dramatic action to prevent "abandonment" (e.g., "I'll kill myself if you leave me!"). They are at significantly higher risk for completed suicide and for substance abuse. A majority of BDL patients report having been sexually abused in childhood. Marsha Linehan's Dialectical Behavioral Therapy (DBT) has been shown to be the most effective treatment for these severely disturbed patients.