Ruwan M Jayatunge M.D.
A personality disorder is an enduring pattern of inner
experience, of seeing the world and relating to others in a manner that
markedly deviates from cultural expectations, and includes, and results in,
problematic and habitual behaviors that are pervasive and inflexible (APA). The first clinical conceptualization of Borderline Personality Disorder (BPD)
was provided in 1975 by Gunderson and Singer. By 1980, the construct of BPD was considered developed and validated to the extent
that the disorder was included in the third edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association 1980) (Ogrodniczuk &Sierra
Hernandez, 2010).
According to Stern (1938) the term ‘borderline’
originally referred to a group of mental illnesses characterized by
psychopathology with features of both psychosis and neurosis, but which did not
clearly meet historical criteria for either group of conditions. Borderline Personality Disorder is a severe
Axis II personality disorder characterized by intense and significant
instability across a number of domains (Rizvi et al., 2011). BPD is the most frequent personality disorder
(Oumaya et al., 2008). It is diagnosed predominantly in women, with an estimated
gender ratio of 3:1. The disorder may be missed in men, who may instead receive
diagnoses of antisocial or narcissistic personality disorder (APA). Borderline symptoms are thought to emerge from
the interaction of temperamental factors and environmental stressors. Both
parental invalidation and attachment disorganization have been hypothesized to
play an etiological role (Lyons-Ruth et al., 2014).
Borderline Personality Disorder is
characterized by severe functional impairments, a high risk of suicide, a
negative effect on the course of depressive disorders, and extensive use of
treatment (Leichsenring et al., 2011). There is
a high rate of stigma associated with BPD (Aviram et al., 2006). Persistent feelings of emptiness are often expressed
by individuals with BPD. They are usually unable to express their aspirations
and desires (Ogrodniczuk &Sierra Hernandez, 2010). In
addition, BPD is marked by impulsivity, instability of mood (Paris, 2005), and deficits in the capacity to work and maintain meaningful relationships (Levy et al., 2006). It is a complex disorder associated with substantial
morbidity, mortality, and public health costs (Stanley & Silver, 2010).
BPD has shown a strong association with substance use
disorders (Gunderson & Links, 2008). BPD patients have a particularly high
vulnerability to the development of Substance Use Disorders over the course of
time (Walter
et al., 2009). Many of the core features of BPD are also
independent risk factors for the development of SUD (Lubman et al., 2011). Persons with a borderline personality disorder often
abuse substances in an impulsive fashion that contributes to lowering the
threshold for other self-destructive behavior such as body mutilation, sexual
promiscuity, or provocative behavior that incites assault (including homicidal
assault) (APA).
According to Few and colleagues (2014), both genetic and
individual-specific environmental factors contribute to comorbidity between
borderline personality features and substance use disorders i.e. that both are impulse spectrum
disorders. Cheetham and colleagues (2010) believe that impulsivity
and affective dysregulation play a key role in the development and maintenance
of addictive disorders. In addition, childhood attachment problems, past trauma,
poor sense of self, and profound state of unease and
dissatisfaction help to maintain addictive behaviors. BPD patients often
use dependence-producing substances in an attempt to mitigate emotions
perceived as overwhelmingly negative or to replace these with a pleasant state,
such as feeling intoxicated (self-medication hypothesis). Apart from that, the
use of addictive substances can also be triggered by factors related to the
social environment, such as peer pressure (Kienast et al., 2014). Substance Use Disorders significantly reduce the likelihood of clinical remission of BPD (Zanarini
et al., 2004; Lubman
et al., 2011).
Challenges
Faced by the Health Care Workers
With patients with borderline personality disorder, there
is a risk of boundary crossings and violations (APA). Moreover, substance use
disorder often complicates the Negative counter-transference or the unconscious
development of negative feelings toward the patient on the part of the
clinician (Lubman et al., 2011). Negative counter-transference is
one of the hindering factors found by therapists while working with clients
diagnosed with BPD (Beatson et al., 2010). Self-destructive behaviors,
anger, mood instability, and pervasive fear of abandonment all interfere with a
clinician’s ability to establish a therapeutic alliance and sustain a successful
treatment (Goodman,
& Siever, 2012). BPD patients have been described as highly
vigilant for social stimuli, especially for social cues that signal social
threat or rejection (Linehan, 1995; Domes et al., 2009). Also, they have a disturbed sense of identity Jørgensen,
2006).
According to Holmes (2003) BPD sufferers lack of meaning
in their lives because they are unable to play 'language games' with their
potential intimates, resorting to actions rather than words to express
feelings. Therefore therapeutic
communication could become substandard. On the other hand BPD sufferers
frequently jeopardize their relationships with the health care providers
creating a deep void in the treatment procedures. As indicated by Lubman and
collogues (2011) management of
co-occurring substance use disorder and borderline personality disorder within
primary care is further compounded by negative attitudes and practices in
responding to people with these conditions, which can lead to a fractured
patient-doctor relationship.
BPD patients often present with quickly fluctuating
complaints and symptoms. Many of the clinical characteristics of patients with
borderline personality disorder may be seen as consequences of disordered
self-organization and a limited rudimentary capacity to think about behavior in
mental state terms (Fonagy, Target & Gergely 2000). Sometimes they blame
their therapists for not addressing fluctuating complaints and symptoms.
BPD patients are psychologically fragile. Psychological
trauma is deeply embedded in PBD. As indicated by Arntz (1994). It is assumed that chronic traumatic abuse or neglect in childhood has
led to the development of almost unshakeable fundamental assumptions about
others (dangerous and malignant), about one’s own capabilities (powerless and
vulnerable) and upon one’s value as a person (bad and unacceptable).
Suicidal behavior often accompanies borderline
personality disorder (Zeng et al., 2015).
Although recurrent suicidal threats, gestures or behaviour or
self-mutilation are common in patients suffering from borderline personality
disorder they often lack systematic suicidal intentions. (Oumaya et al., 2008). However BPD complicated by substance use disorders could lead to complete suicides.
Management
The management of patients with
borderline personality disorder may be difficult, because these patients often
make disproportionate demands on the physician's time and they tend to
experience complicated and/or incomplete recovery from organic or functional illness
(Sansone & Sansone, 1991). Nonetheless management of the
patient-therapist relationship is paramount and may be in itself the most
effective and safe treatment for both crisis situations and longer therapy (Dawson, 1988).
Patients with borderline personality disorder and comorbid
addiction should be treated as early as possible for both conditions in a
thematically hierarchical manner ( Kienast et al., 2014). Psychotherapy is regarded as the first-line treatment
for people with borderline personality disorder (Stoffers et al., 2012). Drug
counseling is a useful component in the treatment process.
Lieb et al (2010), have suggested that mood
stabilisers and second-generation antipsychotics may be effective for treating
specific symptoms of BPD and associated pathology A positive therapeutic relationship
plays a central role in the management of both BPD and SUD (Lubman et al., 2011).
Brown and
Shapiro (2006) provide preliminary
evidence for use of EMDR in the treatment of Borderline
Personality Disorder. van der Hart and collogues (2010) highlight the
significance of EMDR in
trauma-related borderline personality disorder. Wesselmann and team (2012) point out that EMDR
is a treatment mode to improve attachment status in adults and children.
Wetzelaer and colleagues (2014) indicate the efficacy of Schema
therapy in BPD. According to Rizvi, and
colleagues (2011) Dialectical behavior therapy (DBT) has received strong
empirical support and is practiced widely as a treatment for borderline
personality disorder (BPD) and BPD with comorbid substance use disorders
(BPD-SUD). Furthermore ongoing communication between all treatment providers is
essential for a coordinated treatment approach and a designated case
coordinator, who is responsible for managing communication between
professionals, is recommended to ensure splitting does not occur (Lubman et al., 2011). In adding together
other interventions such as Psycho-education, Family therapy also plays an
important role in managing BPD.
Conclusion
Individuals with
borderline personality disorder (BPD) often experience severe functional
impairments, Interpersonal difficulties
higher levels of depressive symptoms, Identity diffusion, feelings of
emptiness, parasuicidal behaviors and many other psychosocial difficulties. In
BPD often the Comorbidity is associated with substance use disorders and it
leads to a complex mental disorder. Although BPD is difficult to treat, patient
- therapist
relationship is paramount to provide services.
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