BORDERLINE

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BORDERLINE

  1. 1. Borderline Personality Disorder
  2. 2. 21 Sep 2007 BOR DERLINE PERS ONA LI TY DISOR DER Borderline Personality Disorder Treatment by John M. Grohol, Psy.D. - June 22, 2007 Table of Contents Introduction • Psychotherapy • Hospitalization • Medications • Self-Help • Introduction Borderline personality disorder is a disturbance of certain brain functions that causes four types of behavioral disturbances: 1. poorly regulated and excessive emotional responses; 2. harmful impulsive actions; 3. distorted perceptions and impaired reasoning; and 4. markedly disturbed relationships. The symptoms of borderline personaliy disorder were first described in the medical literature over 3000 years ago. The disorder has gained increasing visibility over the past three decades. The full spectrum of symptoms of bordelrine personality disorder typically first appears in the teenage years and early twenties. Although some children with significant behavioral disturbances may develop readily diagnosable borderline disorder as they get older, it is very difficult to make the diagnosis in children. After its onset, the disorder becomes chronic. Remissions, relapses, and overall significant improvement with treatment is the most common course of the illness. Borderline disorder appears to be caused by the interaction of biological, usually genetic, and environmental risk factors, such as poor parental nurturing, and early and sustained emotional, physical or sexual abuse. Physical disorders, such as migraine headaches, and other mental disorders, such as depression, anxiety, panic and substance abuse disorders, occur much more often in people with borderline disorder than they do in the general population.
  3. 3. Borderline Personality Disorder is experienced in individuals in many different ways. Often, people with this disorder will find it more difficult to distinguish between reality from their own misperceptions of the world and their surrounding environment. While this may seem like a type of delusion disorder to some, it is actually related to their emotions overwhelming regular cognitive functioning. People with this disorder often see others in “black-and-white” terms. Depending upon the circumstances and situation, for instance, a therapist can be seen as being very helpful and caring toward the client. But if some sort of difficulty arises in the therapy, or in the patient’s life, the person might then begin characterizing the therapist as “bad” and not caring about the client at all. Clinicians should always be aware of this “all-or- nothing” lability most often found in individuals with this disorder and be careful not to validate it. Therapists and doctors should learn to be like a rock when dealing with a person who has this disorder. That is, the doctor should offer his or her stability to contrast the client’s lability of emotion and thinking. Many professionals are turned-off by working with people with this disorder, because it draws on many negative feelings from the clinician. These occur because of the client’s constant demands on a clinician, the constant suicidal gestures, thoughts, and behaviors, and the possibility of self-mutiliating behavior. These are sometimes very difficult items for a therapist to understand and work with. Psychotherapy is nearly always the treatment of choice for this disorder; medications may be used to help stabilize mood swings. Controversy surrounds overmedicating people with this disorder. Psychotherapy Like with all personality disorders, psychotherapy is the treatment of choice in helping people overcome this problem. While medications can usually help some symptoms of the disorder, they cannot help the patient learn new coping skills, emotion regulation, or any of the other important changes in a person’s life. An initially important aspect of psychotherapy is usually contracting with the person to ensure that they do not commit suicide. Suicidality should be carefully assessed and monitored throughout the entire course of treatment. If suicidal feelings are severe, medication and hospitalization should be seriously considered. The most successful and effective psychotherapeutic approach to date has been Marsha Linehan’s Dialectical Behavior Therapy. Research conducted on this treatment have shown it to be more effective than most other psychotherapeutic and medical approaches to helping a person to better cope with this disorder. It seeks to teach the client how to learn to better take control of their lives, their emotions, and themselves through self- knowledge, emotion regulation, and cognitive restructuring. It is a comprehensive approach that is most often conducted within a group setting. Because the skill set
  4. 4. learned is new and complex, it is not an appropriate therapy for those who may have difficulty learning new concepts. Like all personality disorders, borderline personality disorder is intrinsically difficult to treat. Personality disorders, by definition, are long-standing ways of coping with the world, social and personal relationships, handling stress and emotions, etc. that often do not work, especially when a person is under increased stress or performance demands in their lives. Treatment, therefore, is also likely to be somewhat lengthy in duration, typically lasting at least a year for most. Other psychological treatments which have been used, to lesser effectiveness, to treat this disorder include those which focus on social learning theory and conflict resolution. These types of solution- focused therapies, though, often neglect the core problem of people who suffer from this disorder — difficulty in expressing appropriate emotions (and emotional attachments) to significant people in their lives due to faulty cognitions. Providing a structured therapeutic setting is important no matter which therapy type is undertaken. Because people with this disorder often try and “test the limits” of the therapist or professional when in treatment, proper and well- defined boundaries of your relationship with the client need to be carefully explained at the onset of therapy. Clinicians need to be especially aware of their own feelings toward the patient, when the client may display behavior which is deemed “inappropriate.” Individuals with borderline personality disorder are often unfairly discriminated against within the broad range of mental health professionals because they are seen as “trouble-makers.” While they may indeed need more care than many other patients, their behavior is caused by their disorder. Phillip W. Long, M.D. also notes that: “The therapeutic alliance should form within the patient’s real experiences with the therapist and with the treatment. The therapist must be able to tolerate repeated episodes of primitive rage, distrust, and fear. Uncovering is to be avoided in favor of bolstering of ego defenses, in order to eventually allow the patient to be less anxious about potential fragmentation and loss. The goals of therapy should be in terms of life gains toward independent functioning, and not complete restructuring of the personality.”
  5. 5. Hospitalization Hospitalization is often a concern with people who suffer from borderline personality disorder because they so often visit hospital emergency rooms and are sometimes seen on inpatient units because of severe depression. People with this disorder often present in crisis at their local community mental health center, to their therapist, or at the hospital emergency room. While an emergency room is an immediate source of crisis intervention for the patient, it is a costly treatment and regular visits to the E.R. should be discouraged. Instead, patients should be encouraged to find additional social support within their community (including self-help support groups), contact a crisis hotline, or contact their therapist or treating physician directly. Emergency room personnel should be careful not to treat the person with borderline personality disorder in blind conjunction with another set of therapists or doctors who are treating the patient for the same problem at another facility. Every attempt should be made to contact the client’s attending physician or primary therapist as soon as possible, even before the administration of medication which may be contraindicated by the primary treatment provider. Crisis management of the immediate problem is usually the key component to effective treatment of this disorder when it presents in a hospital emergency room, with discharge to the patient’s usual care provider. Inpatient treatment often takes the form of medication in conjunction with psychotherapy sessions in groups or individually. This is an appropriate treatment option if the person is experiencing extreme difficulties in living and daily functioning. It is, however, relatively rare to be hospitalized in the U.S. for this disorder. Long-term care of the person suffering from borderline personality disorder within a hospital setting is nearly never appropriate. The typical inpatient stay for someone with borderline personality disorder in the U.S. is about 3 to 4 weeks, depending upon the person’s insurance. Since this treatment is so expensive, it is getting more difficult to obtain. Results of such treatment are also mixed. While it is an excellent way of helping stabilize the client, it is usually too short a time to attain significant changes within the individual’s personality makeup. Good inpatient care facilities for this disorder should be highly structured environments which seek to expand the individual’s independence. Phillip W. Long, M.D., adds that the goals of such a treatment modality, “include decreasing acting out, clearly identifying and working with inappropriate behaviors and feelings, accepting with the patient the magnitude of the therapeutic task, fostering more effective interpersonal relationships, and working with both real and transference relationships within the hospital.” Partial hospitalization or a day treatment program is often all that’s needed for people who suffer from borderline personality disorder. This allows the individual to gain support and structure from a safe environment for a short time, or during the day, and returning home in the evening. In times of increased stress or difficulty coping with specific situations, this type of treatment is more appropriate and more healthy for most people than full inpatient hospitalization.
  6. 6. Medications Phillip W. Long, M.D. has noted: Medications play three very important roles in the treatment of most patients with borderline disorder. They are effective in reducing the four major groups of symptoms of the disorder. They thereby enhance the rate and quality of improvement derived from psychotherapy. Finally, medications are effective in treating other emotional disorders that frequently are associated with borderline disorder, for example, depression, anxiety/panic attacks, and ADHD, and physical disorders such as migraine headaches. “During brief reactive psychoses, low doses of antipsychotic drugs may be useful, but they are usually not essential adjuncts to the treatment regimen, since such episodes are most often self-limiting and of short duration. It is, however, clear that low doses of high potency neuroleptics (e.g., haloperidol) may be helpful for disorganized thinking and some psychotic symptoms. Depression in some cases is amenable to neuroleptics. Neuroleptics are particularly recommended for the psychotic symptoms mentioned above, and for patients who show anger which must be controlled. Dosages should generally be low and the medication should never be given without adequate psychosocial intervention.” Antidepressant and anti-anxiety agents may be appropriate during particular times in the patient’s treatment, as appropriate. For example, if a client presents with severe suicidal ideation and intent, the clinician may want to seriously consider the prescription of an appropriate antidepressant medication to help combat the ideation. Medication of this type should be avoided for long-term use, though, since most anxiety and depression is directly related to short-term, situational factors that will quickly come and go in the individual’s life. Treatment for Depression Co-occurring with Borderline Disorder If you think you have the symptoms of either type of depression, immediately alert your psychiatrist. If appropriate, the treatment for depression frequently involves the addition of an antidepressant, an increase in dosage if one is already being used, and/or the use of behavioral techniques. There are no controlled studies on the relative effectiveness of different antidepressants for the treatment for depression in people with borderline disorder. However, studies of these disorders in people without borderline disorder, and experience, suggest that the following initial treatment strategies may have merit:
  7. 7. Treatment for Depression in Bipolar Disorder-Depressed • Bupropion (Wellbutrin®) • Lamotrigine (Lamictal®) • SSRIs such as fluoxetine (Prozac®) or sertraline (Zoloft®) if bupropion and lamotrigine are ineffective Treatment for Depression in Major Depressive Disorder • SSRIs such as fluoxetine or sertraline • Bupropion and lamotrigine if SSRIs are ineffective Note: It is important in the treatment for depression to recognize that some antidepressants may cause an episode of mania or hypomania in patients with depression who have never experienced such episodes in the past. Cognitive Behavioral Therapy focused on treatment for depression may also prove useful to help identify thought patterns and behaviors that operate as risk factors for mood disorders, and to encourage new, more successful behaviors. * Bipolar I and II, and major depressive disorders occur more commonly in patients with borderline disorder than they do in the general population. Bipolar II disorder is the most common type of bipolar disorder that occurs with borderline disorder. People with bipolar II disorder do not experience manic episodes as do those with bipolar I disorder, but do experience brief hypomanic periods and recurring episodes of depression. Depressions associated with bipolar disorder appear to be related to depressions referred to as atypical depression and seasonal affective disorder (SAD). Self-Help Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Encouraging the individual with borderline personality disorder to gain additional social support, however, is an important aspect of treatment. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings. Patients can be encouraged to try out new coping skills and emotion regulation with people they meet within support groups. They can be an important part of expanding the individual’s skill set and develop new, healthier social relationships. Education and Support During the past decade, an increasing number of educational and support groups have been formed for patients with borderline disorder, and for their families. Many of these have been the result of the efforts of lay advocacy groups dedicated to increasing knowledge about, and reducing the stigma associated with borderline disorder.
  8. 8. Patient and Family Educational Programs A growing number of educational programs are being conducted for people with borderline disorder and their families. These are often co-sponsored by community organizations working with the assistance of consumer and family organizations such as the National Education Alliance for Borderline Personality Disorder (NEA-BPD), the Treatment and Research Advancements National Association for Personality Disorder (TARA), and the National Alliance on Mental Illness (NAMI). A recent addition to the therapeutic opportunities for family members of people with borderline disorder has been the introduction of family educational and training programs. Family Connections The family education program, Family Connections (FC), is available in multiple locations throughout the US, and at several locations in Canada, Europe and the UK. It operates under the auspices of NEA-BPD with research funding from the National Institute of Mental Health. Experienced family members co-lead the 12-week manualized series of sessions for other families. These sessions provide participants with the most current information and research about borderline disorder, teach DBT and family coping skills, and provide an opportunity to develop a support network. Research documents a reduction in family member depression, burden, and grief and an increase in coping skills. No registration fee is required, but in some locations a donation to cover costs of the course materials is suggested. Family-to-Family The National Alliance on Mental Illness (NAMI) has recently designated borderline disorder as a “priority population.” In doing so, NAMI has now extended its popular 12 week Family Education Program to include this disorder. The course is taught by trained NAMI volunteers in every state in the country. It provides a broad range of information essential to those caring for loved ones with borderline and other serious mental disorders. Family Training Workshop TARA sponsors an eight session DBT family training workshop in New York City and other cities across the country. The main goals of the program are similar to that provided by NEA-BPD. Each training cycle is limited to sixteen members, and a registration fee is required. Support Groups In some communities, groups of people with borderline disorder and family members meet on a regular basis, without a therapist or trained and skilled group leader, to help one another. Such support groups typically do not charge members a fee and can be very beneficial for the reasons cited above for therapist-assisted group therapy.
  9. 9. There are two types of support groups: • groups for the person with borderline disorder • groups for their family members Although it may be helpful, participation in such groups should be approached with caution by the person with borderline disorder or family members. Considerable harm can be done if one or more individuals in the group act in an angry, manipulative, malicious, or otherwise inappropriate and destructive way toward another group member or the group as a whole. Without a skilled leader or facilitator present to step in to handle the situation promptly and properly, a member of the group, and even the group itself, may be exposed to significant trauma. Prior to joining a support group, it is wise to seek recommendations about groups in your community from your nearest NAMI Chapter, or from mental health professionals working with patients with borderline disorder. In addition, it may be helpful to request information from members of such groups before joining. Symptoms of Borderline Personality Disorder by John M. Grohol, Psy.D. - June 22, 2007 The main feature of borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image and emotions. People with borderline personality disorder are also usually very impulsive. This disorder occurs in most by early adulthood. The instable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships and the person’s emotion may often be characterized as being shallow.
  10. 10. A person with this disorder will also often exhibit impulsive behaviors and have a majority of the following symptoms: Frantic efforts to avoid real or imagined abandonment • A pattern of unstable and intense interpersonal relationships characterized by • alternating between extremes of idealization 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 abuse, reckless driving, binge eating) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior • Affective 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 • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays • of temper, constant anger, recurrent physical fights) Transient, stress-related paranoid ideation or severe dissociative symptoms • Details about Borderline Personality Disorder Symptoms Frantic efforts to avoid real or imagined abandonment. The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, emotion, thinking and behavior. Someone with borderline personality disorder will be very sensitive to things happening around them in their environment. They experience intense abandonment fears and inappropriate anger, even when faced with a realistic separation or when there are unavoidable changes in plans. For instance, becoming very angry with someone for being a few minutes late or having to cancel a lunch date. People with borderline personality disorder may believ that this abandonment implies that they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors.
  11. 11. Unstable and intense relationships. People with borderline personality disorder may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficient supports or as cruelly punitive. Such shifts other reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected. Identity disturbance. There are sudden and dramatic shifts in self-image, characterized by shifting goals, values and vocational aspirations. There may be suddent changes in opinions and plans about career, sexual identity, values and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with borderline personality disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations. Display self-damaging impulsivity Individuals with Borderline Personality Disorder display impulsivity in at least two areas that are potentially self-damaging. They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly.
  12. 12. Display recurrent suicidal behavior Individuals with Borderline Personality Disorder may also sometimes display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common. Recurrent suicidality is often the reason that these individuals present for help. These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility. Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual’s sense of being evil. Display affective instability Individuals with Borderline Personality Disorder may display affective instability that is 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). The basic dysphoric mood of those with Borderline Personality Disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do. Individuals with Borderline Personality Disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver’s nurturance may result in a remission of symptoms. Associated Features and Disorders Individuals with Borderline Personality Disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body- image distortions, ideas of reference, and hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships. Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring Mood Disorders or Substance-Related Disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and broken marriages are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or
  13. 13. separation are more common in the childhood histories of those with Borderline Personality Disorder. Common co-occurring Axis I disorders include Mood Disorders, Substance-Related Disorders, Eating Disorders (notably Bulimia), Posttramatic Stress Disorder, and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder also frequently co-occurs with the other Personality Disorders. Specific Culture, Age, and Gender Features The pattern of behavior seen in Borderline Personality Disorder has been identified in many settings around the world. Adolescents and young adults with identity problems (especially when accompanied by substance abuse) may transiently display behaviors that misleadingly give the impression of Borderline Personality Disorder. Such situations are characterized by emotional instability, quot;existentialquot; dilemmas, uncertainty, anxiety- provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers. Borderline Personality Disorder is diagnosed predominantly (about 75%) in females. Prevalence The prevalence of Borderline Personality Disorder is estimated to be about 2% of the general population, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients. In ranges from 30% to 60% among clinical populations with Personality Disorders. Course There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Familial Pattern Borderline Personality Disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for Substance-Related Disorders, Antisocial Personality Disorder, and Mood Disorders. Differential Diagnosis Borderline Personality Disorder often co-occurs with Mood Disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional presentation of Borderline Personality Disorder can be mimicked by an episode of Mood Disorder, the clinician should avoid giving an additional diagnosis of Borderline Personality Disorder based only on cross-sectional presentation without having documented that the pattern of behavior has an early onset and a long-standing course.
  14. 14. Look-alikes Other Personality Disorders may be confused with Borderline Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Borderline Personality Disorder, all can be diagnosed. Although Histrionic Personality Disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, Borderline Personality Disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both Borderline Personality Disorder and Schizotypal Personality Disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in Borderline Personality Disorder. Although Paranoid Personality Disorder and Narcissistic Personality Disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns distinguish these disorders from Borderline Personality Disorder. Although Antisocial Personality Disorder and Borderline Personality Disorder are both characterized by manipulative behavior, individuals with Antisocial Personality Disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in Borderline Personality Disorder is directed more toward gaining the concern of caretakers. Both Dependent Personality Disorder and Borderline Personality Disorder are characterized by fear of abandonment, however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline Personality Disorder can further be distinguished from Dependent Personality Disorder by the typical pattern of unstable and intense relationships. Borderline Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified). Borderline Personality Disorder should be distinguished from Identity Problem...which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.quot;
  15. 15. Frequently Asked Questions about Borderline by John M. Grohol, Psy.D. - June 22, 2007 What is Borderline Personality Disorder (BPD)? The main feature of borderline personality disorder (BPD) is a long pattern of instability in their relationships with others, and in their own self-image and emotions. People with borderline personality disorder are also usually very impulsive. The instable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships and the person’s emotion may often be characterized as being shallow. The disorder occurs in most by early adulthood. How common is Borderline Personality Disorder? It is not very common, and is estimated to be found in 1 to 2% of the general U.S. population at any give time. It is more common amongst people seeking treatment for another mental disorder. How does Borderline Personality Disorder cause problems? Like any mental health issue, borderline personality disorder causes problems in a person’s social and life functioning by interfering with the person’s ability to reliably maintain these relationships or their everyday living. People with this disorder often cause a great amount of stress or conflict in relationships with others, especially significant others or those who are very close to the person. This can often lead to divorce, physical, sexual or emotional abuse, additional emotional problems (such as an eating disorder or depression), losing one’s job, estrangement from one’s family, and more. What is the course of Borderline Personality Disorder? There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious loss of emotion and impulsive control, as well as high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and job functioning.
  16. 16. Is Borderline Personality Disorder inherited? Borderline Personality Disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for Substance-Related Disorders (e.g., drug abuse), Antisocial Personality Disorder, and Mood Disorders, like depression or bipolar disorder. Where can I go to learn more about Borderline Personality Disorder? Psych Central has a reviewed list of resources you can consult for further information about Borderline Personality Disorder. We also recommend the following two books to understand more about this disorder: Stop Walking on Eggshells: Taking Your Life Back • When Someone You Care about Has Borderline Personality Disorder by Paul T. Mason and Randi Kreger • The Stop Walking on Eggshells Workbook: Practical Strategies for Living With Someone Who Has Borderline Personality Disorder by Randi Kreger and James Paul Shirley FOR LOVED ONES People with borderline disorder have marked difficulties with relationships, especially with the people who are closest to them, such as families, partners and friends. Episodes of anger outbursts, moodiness, and unreasonable, impulsive, and erratic behaviors, which often appear unprovoked, can result in considerable harm to these important relationships. Attempts to engage in a discussion to work out reasonable solutions to problems frequently turn into highly emotional battles. This usually results in responses from family, partners and friends that include anxiety and frustration, attempts to placate, and angry retorts when the limits of normal patience have been exceeded. Therefore, most loved ones of individuals with borderline disorder are quite relieved to learn that effective treatment is available for the disorder, and that there are ways they can help as well. Two significant advances in the area of borderline disorder have been the recent research on the effectiveness of different educational and therapeutic experiences for families, and the development of consumer and family organizations focused on the disorder.
  17. 17. Ten Guidelines for Families, Partners and Friends If you are a family member, partner or friend of someone with borderline disorder, you probably have developed feelings of anger and resentment towards them that conflict with your feelings of empathy and desire to help. The following are ten specific actions that you can take that will help the person with borderline disorder gain better control over her or his life, and help you in the process. 1. Learn About the Disorder It is essential to understand that the person with borderline disorder is suffering from an illness that is as real as diabetes, heart disease, or hypertension. For most people, physical symptoms are easier to accept as indications of a disease than are behavioral symptoms. However, there is no reason to assume that a complex organ such as the brain is less susceptible to diseases that affect behavior than are other bodily organs that result in physical symptoms. Recently developed medical research studies demonstrate abnormal brain structure and function in patients with borderline disorder, thus confirming this conclusion. It is also helpful to realize that persons with borderline disorder did not acquire the disorder through any actions of their own, nor do they enjoy having the disorder. Imagine what it must be like to feel that you are frequently at the mercy of forces within you, over which you seem to have little control, and that cause you extreme emotional pain and significant life problems. Therefore, a critical first step in the process of helping them and you is to learn as much as you can about the symptoms and nature of borderline disorder, and the specific situational causes of acute episodes in the member of your family with the disorder. 2. Seek Professional Help Facilitate the process of obtaining optimal help. It may be necessary that you do the initial work necessary to set up the first appointment. It may also be helpful if you agree to go also. Some people with borderline disorder initially refuse to seek professional help. Provide them with a copy of my book and suggest they read the first two chapters. This may help them understand their potential problems well enough to agree to an initial appointment with a psychiatrist. Other people with borderline disorder are steadfast in their refusal of help. This, of course, is a major problem. Dr. Perry Hoffman, the founding president of the National Education Alliance for Borderline Personality Disorder (NEA-BPD) offers this advice: The best way of approaching this problem from my perspective is for one to accept that you cannot get someone into treatment. Timing is important as to when someone might be “open” to hearing the idea. But the bottom line is to free families of feeling
  18. 18. guilty, and to understand that they are not so powerful to effect that goal. Along that line, relatives need to get help and support for themselves as they watch their loved one in the throes of the illness. 3. Support the Treatment Program Once in treatment, encourage and support your loved one with borderline disorder to regularly attend therapy sessions, to take medicine as prescribed, to eat, exercise, and rest appropriately, and to engage in wholesome recreational activities. If alcohol or other drugs are a problem, strongly support their efforts to abstain completely from these substances, and encourage regular attendance in treatment programs or self-help groups, such as Alcoholics Anonymous. Remember, there is little hope of improvement of the symptoms of borderline disorder if alcohol and drugs are abused. It is very important that you remain persistent in your efforts to do everything possible to help reduce the risk of this behavior, and not enable it. 4. Respond Consistently to Problematic Behaviors Develop a clear understanding (it may even be written) of the realistic consequences of recurring, problematic, destructive behaviors such as episodes of alcohol and drug abuse, physically self-damaging acts, and excessive spending and gambling. Also, agree beforehand on how best to respond to threats and acts of self-harm. These and other problematic behaviors are often triggered by stressful events that need to be identified, and a clear plan developed for handling these events and situations more appropriately and effectively in the future. Such a plan is best developed with the help of the patient’s primary clinician. Experience has shown that responding positively to appropriate behaviors is also very important in encouraging change to new and more successful ways of handling stressful situations. Doing so also reduces the incidence of inappropriate behaviors that then cause additional problems. Issuing spontaneous ultimatums should be avoided. 5. Attempt to Remain Calm Reacting desperately or angrily when there is a flare up of symptoms will often add to the existing problem. Remain calm. Acknowledge that it must be difficult to experience the expressed feelings, even if they seem out of proportion to the situation. This does not mean that you agree with these feelings, or that you think that the actions resulting from them are justified. However, it is reassuring if you listen to their feelings, the pain they are experiencing, and the difficulty they are having in dealing with this pain. Remember that you do not have to defend yourself if verbally attacked, or develop solutions to their problems. If
  19. 19. they express thoughts of self-harm, remind them of the plan for dealing with this problem that has been worked out with their therapist. Allow and encourage the person with borderline disorder to attempt to bring their response levels in line with the situation at hand. This may require that you give them a little time alone to collect themselves. Then it may be possible to more calmly and reasonably discuss the relevant issues. In addition, do not be hesitant to express your feelings freely and openly, but with moderation. Recent research suggests that caring involvement with your loved one with borderline disorder is associated with better outcomes than a cool, disinterested approach. Stay involved. 6. Remain Positive and Optimistic It is important to remain optimistic about the ultimate results of treatment, especially when the patient has a setback. The usual course of borderline disorder with optimal treatment is one of increasing periods of time when symptoms are absent or minimal, interrupted by episodes when the symptoms flare up. Over time, the specific causes of relapses can be identified, anticipated, then steps taken to develop alternative, more adaptive and effective responses. Occasional family meetings with the therapist may help clarify the causes of relapses and identify new ways of preventing them.
  20. 20. 7. Participate in Educational Experiences About Borderline Disorder It is very important that you learn as much as possible about borderline disorder and your role in the treatment process. Your participation in educational opportunities may benefit both you and your loved one with the disorder. When conducted by skilled and experienced people, such structured and informative experiences may involve both patients and family. 8. Join a Borderline Disorder Consumer and Family Support Organization For information on such consumer organizations, contact the National Alliance on Mental Illness (NAMI) or the National Education Alliance for Borderline Personality Disorder (NEA-BPD). If such an organization exists in or near your community, seriously consider joining it. You will then have available to you a large amount of new information about borderline disorder, what you can do to help the member of your family with the disorder and yourself, and compassionate and understanding support in your efforts. If there is not a group in your area, consider starting one with other family members you have met. Also consider joining one of these national consumer organizations for borderline disorder. 9. Remember: the Person with Borderline Disorder Must Take Charge Remember that it is primarily the responsibility of the person with borderline disorder to take charge of her or his behavior and life. Although difficult at times, it is important for you to provide the opportunity for your family member with borderline disorder to take reasonable risks in order to try new behaviors. It is also important that you help her or him to be accountable for the consequences of old, destructive behaviors. Excessive dependency on family and friends is not helpful in the long run. Beware of the tendency of people with borderline disorder to act at the extremes. For example, the proper alternative to excessive dependency is not immediate, total independency. The more appropriate responses are to remain engaged and to gradually help move to a more balanced, mature relationship level of mutual interdependency. 10. Take Care of Yourself If you take the time to meet your own needs, when your help is needed most, you will be best able to provide it. Remember that you cannot save your loved one with borderline disorder on your own. If you are the parent, there is a natural tendency to focus much of your attention on the person with borderline disorder. However, make certain that you are not neglecting your other sons and daughters who may appear to be doing well. They have need of your time
  21. 21. and attention too, even as they grow into adulthood. You will learn from educational experiences the extent of this potential problem and how best to deal with it. THE WORLD NEEDS PEOPLE... who cannot be bought; whose word is their bond; who put character above wealth; who possess opinions and a will; who are larger than their vocations; who do not hesitate to take chances; who will not lose their individuality in a crowd; who will be as honest in small things as in great things; who will make no compromise with wrong; whose ambitions are not confined to their own selfish desires; who will not say they do itquot; because everybody else does itquot;; who are true to their friends through good report and evil report, in adversity as well as in prosperity; who do not believe that shrewdness, cunning, and hardheadedness are the best qualities for winning success; who are not ashamed or afraid to stand for the truth when it is unpopular; who can say quot;noquot; with emphasis, although all the rest of the world says quot;yes.quot; - Charles Swindoll.
  22. 22. ONLINE TEST The following quot;testquot; may help you to evaluate the possibility that you or a loved one has borderline disorder. It is simply a check list of the nine criteria of borderline disorder as defined by the American Psychiatric Association in their diagnostic manual, DSM-IV-TR. However, it is reworded so that you may readily apply the criteria to your situation. Please note that you should not use the results of the test to arrive at any fixed conclusion, but rather to provide you with an estimation of the possibility that this disorder, or its traits, may exist. How to Use the Borderline Disorder Test First, read carefully about the symptoms of borderline disorder provided on this website, or as they are described in more detail in my book, Borderline Personality Disorder Demystified. Next, print this page and place a check mark next to those symptoms or behaviors listed below that you believe accurately describe your condition. If you are in doubt, leave the item blank. The Borderline Disorder Test 1) My emotions change very quickly, and I experience intense episodes of sadness, ___ irritability, and anxiety or panic attacks. ___ 2) My level of anger is often inappropriate, intense and difficult to control. ___ 3) I suffer from chronic feelings of emptiness and boredom. 4) I engage in two or more self-damaging acts such as excessive spending, unsafe ___ and inappropriate sexual conduct, substance abuse, reckless driving, and binge eating. 5) Now, or in the past, when upset, I have engaged in recurrent suicidal behaviors, ___ gestures, threats, or self-injurious behavior such as cutting, burning or hitting myself. 6) I have a significant and persistently unstable image or sense of my self, or of who ___ I am or what I truly believe in. 7) I have very suspicious ideas, and am even paranoid (falsely believe that others are ___ plotting to cause me harm) at times; or I experience episodes under stress when I feel that I, other people or the situation is somewhat unreal. 8) I engage in frantic efforts to avoid real or imagined abandonment by people who ___ are close to me. 9) My relationships are very intense, unstable, and alternate between the extremes of ___ over idealizing and undervaluing people who are important to me.
  23. 23. How to Score the Borderline Disorder Test Score of five or greater: If you have checked five or more items on the above list, you may have borderline disorder. In order to determine if this is the case, you will require an evaluation by a psychiatrist or mental health care clinician who is well trained and experienced in borderline disorder. Score of one to four: If you have checked one to four items on the above checklist, you may have borderline disorder traits. Depending on the level of severity of your symptoms or behaviors, and the amount of disruption that they cause you, your family, friends and others, you may require an evaluation by a psychiatrist or mental health care clinician who is well trained and experienced in borderline disorder. It is important to realize that you do not have to meet five or more criteria of borderline disorder for these symptoms to significantly disrupt your life. You may still benefit greatly from appropriate treatment. Guidelines for the Selection of a Psychiatrist and Other Clinicians Once you have located the names of one or more clinicians, you may wish to contact them to determine if they provide the services you are looking for. The following is a list of issues that you may wish to clarify in order to determine if you have a reasonably suitable fit given your individual needs: Primary Clinician: Ideally, in most cases, you are looking for a psychiatrist with experience in borderline disorder who can serve as your primary clinician, that is, perform your initial clinical evaluation and the other tasks of someone assuming this role in your care. If such a person is not available in your community, you should ask other potential providers of care about their level of experience in the area of borderline disorder. Types of Treatment: Determine what forms of treatment they typically use for their patients with the disorder, especially medications and psychotherapies. Most psychiatrists and other clinicians do not typically provide the full range of treatments that we now know are useful for treating the disorder. In other words, you may need several people working with you, for example, one to prescribe medications, another to provide therapy, and possibly a third for group therapy work. Therefore, you will need to ask how your special needs will be met by each clinician. If you will be seeing just one person, be especially cautious if they recommend only one form of treatment for all patients with borderline disorder, for example either medications or psychotherapy, or one specific type of psychotherapy. As noted elsewhere on this site, borderline disorder affects people
  24. 24. in many different ways. Therefore, in most cases, effective treatment plans are more complex than can be accomplished by a single type of treatment. Immediate Help: You should establish how the provider handles those times when you may need immediate help, for example who will respond to your telephone calls and under what circumstances. Also, should you require brief hospitalization, what hospital will be utilized, and who will direct your care when you are in the hospital. Communication: If you will have more than one clinician working with you, it is important to establish the degree to which they will work with you and with your family or partner, and with each other. It is important that the team communicate openly. Under most circumstances, it is essential that those people who are very important in your life are included in your treatment. The types and frequency of involvement required are best discussed prior to the onset of treatment. Finding the Right Fit: Ultimately, you are looking for clinicians who appear to be “good fits” for you and your special needs. To some degree this is a subjective quality, and cannot be easily defined further, but patients often sense when they have found the right professionals with whom to work. Credentials: It is very appropriate to ask about the potential provider’s specific credentials: in what mental health specialty do they have their degree; are they certified properly, for example., for psychiatrists, by the American Board of Psychiatry and Neurology; are they licensed to practice in their specific clinical area; and what degree of training and experience do they have with borderline disorder. Payment Information: Finally, you should obtain their fee schedule and method of payment for different services, for example medication checks, and individual and group psychotherapy sessions. Many clinicians accept insurance with co-payments, while some require self payment. At the outset of care, remember that your doctor may not be able to determine precisely the most effective treatments for you. Therefore, it seems to me most reasonable to find a psychiatrist, and other clinicians when necessary, who know the relevant medical literature, that have open minds regarding different diagnostic possibilities and treatment approaches, and who communicate well with you and your family. Given our current level of knowledge about borderline disorder, it is likely that such professionals will give you the best help available, now and in the future.
  25. 25. The Diagnosis and Treatment for Depression Co- Occurring with Borderline Disorder by Robert O. Friedel, MD More than 80 percent of people with borderline disorder suffer from episodes of major depression. Treatment for depression is vital in these individuals. There are two categories of major depressive episodes, those associated with bipolar I and II disorder- depressed*, and those referred to as major depressive disorder. Therefore, if you have borderline disorder, it is important that you know and recognize the symptoms of these disorders. If they occur, you should alert your physician so that you may receive prompt treatment for depression. Symptoms of a Major Depressive Episode: persistently depressed or irritable mood • diminished interest or pleasure in activities • significant decrease or increase in appetite, or weight loss or • weight gain increased or decreased sleep • decreased mental and physical activity, or increase in such activity as • demonstrated by excessive worrying and agitated behavior fatigue, or loss of energy • feelings of worthlessness or excessive or inappropriate guilt • diminished ability to think or concentrate, or indecisiveness • recurrent thoughts of death and dying, recurrent suicidal thoughts with a specific • plan, or a suicide attempt Understand the differences in symptoms of Borderline Disorder, Bipolar Disorder-Depressed and Major Depressive Disorder, and learn about the various plans for treatment for depression. In order to initiate the proper treatment for depression, it is necessary to determine if you are experiencing a decrease in mood associated with borderline disorder, or if you have developed a bipolar II disorder- depressed or major depressive disorder. Depressed Mood in Borderline Disorder In borderline disorder alone, depressed mood often occurs as follows: • sad, depressed, and lonely feelings are frequently triggered by some life event and are often associated with strong feelings of emptiness, loneliness and fears of abandonment. • symptoms readily improve if the situation causing them improves • sleep, appetite and energy disturbances (if present) are usually related to an identifiable life stress and stop when the stress is managed successfully. • acute suicidal thoughts and self-injurious behavior are usually the direct result of a personal problem (for example, an argument with a parent, boyfriend, spouse, or boss)
  26. 26. Bipolar II Disorder-Depressed* In bipolar disorder-depressed, the symptoms of a major depressive episode listed above are often characterized by: • increased appetite or weight gain • increased sleep and napping • marked decrease in mental and physical activity • marked fatigue and loss of energy Major Depressive Disorder In major depressive disorder, the symptoms of a major depressive episode listed above are often characterized by: • decreased appetite or weight loss • decreased sleep with early morning awakening • increased mental and physical activity as demonstrated by excessive worrying and agitated behavior Substance Abuse Treatment in Patients with Borderline Disorder by Robert O. Friedel, MD Two-thirds of people with borderline disorder seriously abuse alcohol, street drugs, and/or prescribed drugs. This is a major factor resulting in poor outcome of people with borderline disorder. Alcohol and drugs are abused by people with borderline disorder to temporarily relieve the severe emotional pain that they experience, especially when under stress. Predictably, this relief is short lived. Even worse, the use of these substances markedly increases many of the symptoms of borderline disorder making substance abuse treatment all the more important. It is possible that some of the genetic alterations that are risk factors in borderline disorder may also be among the group of genes that predispose people to alcoholism and drug abuse. DSM-IV-TR Criteria for Substance Use Disorders: There are two types of substance use disorders, substance dependence and substance abuse. Substance abuse treatment is important in both types of substance use disorders. Substance Dependence A pattern of substance use that leads to significant impairment or distress in three (or more) of the following ways:
  27. 27. • tolerance, as defined by either o a need for markedly increased amounts of the substance to achieve the desired effect, or o a markedly diminished effect with continued used of the same amount of the substance • withdrawal symptoms characteristic for the substance, or increased use to relieve or avoid withdrawal symptoms • the substance is taken in larger amounts or over a longer period than intended • a persistent desire or unsuccessful efforts to cut down or control substance use • much time is spent in activities to obtain the substance, use the substance, or recover from its effects • important social, occupational, or recreational activities are given up or reduced • the substance use is continued despite it causing a persistent or recurrent physical or psychological problem (e.g., current cocaine use despite recognition of cocaine-induced depression)
  28. 28. Self-Injurious Behaviors and Suicidality in Borderline Disorder by Robert O. Friedel, MD In a recent study, approximately 75 percent of women with borderline disorder engaged in self-injurious behaviors such as cutting, burning and small drug overdoses. Cutting is by far the most common act of this type. About 9 percent of people with the disorder commit suicide. The most frequent means is by drug overdose. Both types of behavior may occur in the same individual. Cutting behaviors double the risk of suicide in people with borderline disorder. Self-Injurious Behaviors In addition to cutting and burning themselves, and taking small drug overdoses, people with borderline disorder hit themselves, pull out their hair, scratch their skin to the point they open wounds, and injure themselves in other ways. Most people with the disorder who injure themselves report that they do so mainly to decrease the intense emotional pain they experience. Remarkably, they also often report that the first time they engaged in cutting and other self injurious behaviors, the idea just came to them. Finally, they report that these acts usually do result in brief emotional relief. It is important that family and other loved ones understand that this is the main motive of self injurious behaviors, not primarily to manipulate the situation or the people around them, though this is often a secondary motive.
  29. 29. Risk Factors for Suicidality There are a number of factors that increase the risk that a person with borderline disorder will commit suicide. Although nothing can be done to reverse some of these factors, others are highly treatable, and deserve immediate attention. co-occurring disorders • antisocial personality disorder (higher in males) • major depression • substance abuse* • personality characteristics • impulsive aggression • poor emotional control • hopelessness • history and severity of childhood sexual abuse • age over 30 years • number of prior self-injurious behaviors and suicide attempts • no prior treatment, or extensive and unsuccessful treatment history • Prevalence Across the Life Cycle: Self-injurious behaviors do not appear to decrease or “burn out” with increasing age in people with borderline disorder, as do other aggressive and impulsive behaviors Management of Self-Injurious Behaviors and Suicidality General Treatment Interventions for Self-Injurious Behaviors and Suicidality: careful evaluation • determine the level of intent and risk of • self-injurious behaviors and suicide - overt and unstated directly involve the patient and family in the • process treat at the least restrictive level of care for • the shortest period of time indicated aggressively treat all co-occurring disorders • modify the treatment to accommodate the • significant increase in severity of borderline disorder symptoms highly structure the environment • identify and promptly address precipitating events • assure involvement and coordination of the entire treatment team, including the • family continue to balance risk vs. reward •
  30. 30. Specific Treatment Interventions: Medications Purposes • reduce or eliminate co-occurring disorders, such as major depressive episodes, substance abuse, ADHD and anxiety disorders • reduce core symptoms of borderline disorder: e.g., emotional dysregulation; aggressive-impulsivity; and cognitive-perceptual impairment Specific Treatment Interventions: Psychotherapy (dialectical behavior therapy-DBT; supportive therapy) Purposes reduce self-injurious behaviors and suicidality decrease the frequency of hospitalizations * Note: If you have borderline disorder and have a tendency to abuse alcohol or drugs, it is essential that you obtain help to abstain completely from doing so. Substance Abuse A pattern of substance use that leads to significant impairment or distress in one (or more) of the following ways: • a failure to fulfill major role obligations at work, school, or home • recurrent substance use in situations in which it is physically hazardous • recurrent substance-related legal problems • continued substance use despite having persistent or recurrent social or interpersonal problems caused or worsened by the effects of the substance
  31. 31. Consequences of Abuse of Alcohol and Street Drugs in Borderline Disorder dramatic worsening of the symptoms of borderline disorder • marked decrease in the effectiveness of medications and psychotherapy. • addiction to and sustained craving for these substances. Substance Abuse Treatment Interventions For all of these reasons, for substance abuse treatment purposes, I strongly advise my patients with borderline disorder to not use alcohol, to not take any street drugs, and to take prescribed medications only as ordered by their physicians. In addition, I encourage those patients who have a substance-use disorder to engage fully in a substance abuse treatment program and attend support groups (Alcoholics Anonymous or Narcotics Anonymous). I also suggest to some of them that they may benefit from a trial on a medication appropriate for their specific drug dependency, as this may help reduce craving and use. Conclusions Substance use disorders are major predictors of poor short- and long-term outcome of borderline disorder. There is little or no hope of gaining control over the symptoms of borderline disorder while alcohol and other drugs are being used, no matter how appropriate the substance abuse treatment program is otherwise. Substance abuse treatment is essential if this problem co-occurs with borderline disorder.
  32. 32. Anxiety and Panic Attack Symptoms Co- Occurring with Borderline Disorder by Robert O. Friedel, MD Have you or a loved one been diagnosed with borderline disorder and are suffering from anxiety and panic attack symptoms? Read the following article and learn more about these symptoms and how they are treated. Anxiety and panic attack symptoms are common in people with borderline disorder. Anxiety disorders occur in almost 90% of people with the disorder. If you have borderline disorder, you may experience heightened levels of anxiety and panic attack symptoms, especially at times of stress. For example, this may occur when you feel you are personally criticized and rejected, or during periods of separation from people who are very important to you. Moderate to severe anxiety may also lead to physical symptoms, such as migraine headaches, abdominal pain and irritable bowel syndrome. Panic Attacks A panic attack is an acute and severe form of anxiety that occurs in about 50% of people with borderline disorder. Panic attacks are characterized by a discrete period of intense fear in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes: • palpitations, pounding heart, or increased heart rate • sweating • trembling or shaking • sensations of shortness of breath or smothering feeling of choking • chest pain or discomfort • nausea or abdominal distress • feeling dizzy, unsteady, lightheaded, or • faint • feelings of unreality or being detached from oneself fear of losing control or going crazy • fear of dying • numbness or tingling sensations • chills or hot flushes • Symptoms can appear unexpectedly and suddenly, for no apparent reason, and disappear either rapidly or slowly. People who suffer from anxiety and panic attack symptoms may also be fearful of placing themselves in circumstances from which escape may be difficult or embarrassing such as elevators, shopping malls and movie theaters. This is referred to as agoraphobia.
  33. 33. Treatment of Anxiety and Panic Attack Symptoms in Borderline Disorder Effective treatment of disabling anxiety and panic attack symptoms in people with borderline disorder should be initiated promptly when these disorders occur. Such treatment usually consists of the use of medications and behavioral techniques. The use of medications to treat anxiety and panic attack symptoms in patients with borderline disorder must proceed with care. This is so because these disorders are commonly treated with benzodiazepines (Xanax, Klonopin, Valium, etc.), that have been found to be harmful in most patients with borderline disorder because they increase impulsivity and have addictive potential. Therefore, in borderline disorder, other classes of medications are often required, such as a temporary increase in the neuroleptic, atypical antipsychotic or antidepressant medication being used to treat the disorder. Initiating the use of an antipsychotic agent or an antidepressant may prove effective for moderate to severe anxiety and panic attack symptoms if one is not already prescribed. In addition, a course of cognitive behavioral therapy, or of biofeedback, specifically tailored to target anxiety and panic attack symptoms are often considered as part of the long-term treatment of these problems. The Symptoms and Treatment of Attention Deficit Hyperactivity Disorder in Patients with Borderline Disorder by Robert O. Friedel, MD Background Attention deficit hyperactivity disorder (ADHD) occurs in about 25% of people with borderline disorder; 5 times more often than it does in the general population. The symptoms of ADHD include decreased attention and concentration, easy distractibility, difficulty in the completion of tasks, and poor management of time and the space area that you use. These symptoms of ADHD result in significantly impaired school, work and social performance, and are described in detail below. ADHD is estimated to occur in about 5% of school age children. It is more common in boys than in girls. There are subtypes associated with hyperactivity and normal activity levels. The hyperactive subtype is much more common in boys, while the inattentive subtype (the subtype with normal activity levels) is somewhat more evenly distributed among boys and girls. The symptoms of ADHD are now known to persist into adulthood in many people, and to require continued treatment. There is often a strong family history of ADHD.
  34. 34. Identifying the symptoms of ADHD in patients with Borderline Disorder is critical for their treatment plan. Symptoms of ADHD* Inattention • fails to give close attention to details or makes careless mistakes in school work, work, or other activities • has difficulty sustaining attention in tasks or play activities • does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) • has difficulty organizing tasks and activities • avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • loses things necessary for tasks or activities (e.g., toys, school assignment, pencils, books, or tools) • is easily distracted by extraneous stimuli • is often forgetful in daily activities Hyperactivity • fidgets with hands or feet or squirms in seat • leaves seat in classroom or in other situations in which remaining seated is expected • runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) • has difficulty playing or engaging in leisure activities quietly • is often “on the go” or often acts as if “driven by a motor” • talks excessively Impulsivity • blurts out answers before questions have been completed • has difficulty awaiting turn • interrupts or intrudes on others (e.g., butts into conversations or games)
  35. 35. Treatment of ADHD in Patients with Borderline Disorder It is not uncommon for children, teenagers and adults with borderline disorder who have some symptoms of ADHD to be misdiagnosed with ADHD, and then receive customary treatment with stimulants such as methylphenidate or an amphetamine derivative. People with borderline disorder treated with these medications typically do not do well, and may even do worse than without these medications. If borderline disorder and ADHD co- occur, patients often do worse when treated for ADHD if they first receive a medication for the symptoms of ADHD. Under these circumstances, they may then demonstrate an increase in emotionality and aggressive impulsivity. Fortunately, clinical experience and anecdotal reports in the scientific literature suggest that this problem can be effectively managed in one of two ways. When the symptoms of ADHD are mild, behavioral treatments alone may be effective, thereby avoiding the risk of increasing the symptoms of borderline disorder with a stimulant. However, if medications are required to bring the symptoms of ADHD under optimal control, it appears to be helpful to initiate treatment with a low dose of a neuroleptic or antipsychotic agent for the symptoms of borderline disorder. Doing so then appears to permit the use of a stimulant to produce a beneficial effect on the symptoms of ADHD with a minimal risk of worsening the core symptoms of borderline disorder. *Adapted from DSM-IV-TR. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

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