Borderline personality disorder: Part nature, part nurture

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Tami Green says she never really felt sure of herself while growing up. The few times she felt confident lasted for a short period before the self-doubt reared itself again. She dealt with her shifting sense of self through isolation and getting lost in her thoughts, she says.

The first time she let herself wander away in her own head was at 4 years old.

“My fragile sense of self also led to a lot of other symptoms, like getting really hurt and frustrated by small, even well-intended, criticism of others,” Green says today.

As a teenager, Green, a Houston resident, began using drugs and suffered from depression and a low self-esteem. A lifelong fear of abandonment followed her as she got older and became more depressed, eventually becoming suicidal and extremely emotional. “I drove those I loved far away by being irritable, raging at them, by my depression and tears,” she adds.

She began going to therapy, hopping from one therapist to another trying to find out what made her feel so empty and sad.

The first time someone suggested to her she might have borderline personality disorder, she says she was shocked and rejected the idea completely.

“Even with as much distress as I was in, I didn’t believe I could have borderline personality disorder,” says Green, adding that people rarely arrive in therapy with a self-diagnosed personality disorder. “Family and friends usually push us into trying to see it.”

When she read the American Psychiatric Association’s nine criteria for the disease, she was even more positive she didn’t have it.

But the diagnosis also meant Green, 47, finally had an answer after years of searching. Finally, she says, she had a “cure” to what had been bothering her all her life.

Characterized by impulsive actions, unstable moods and chaotic and intense relationships, it is difficult to say with accuracy how many people in the U.S. have borderline personality disorder, or BPD, given the difficulty in diagnosing the condition. The National Institute of Mental Health estimates that BPD afflicts approximately 2 percent of U.S. adults.

Although the root cause of BPD is not known, medical professionals believe there are two components to developing the personality disorder, says Perry Hoffman, president of the National Education Alliance for BPD.

“We think there is a biological piece and an environmental piece, and when they come together it lays fertile ground for the development of the disorder,” says Hoffman. “The biological piece is partially genetic and the social-environment piece is something that happens in the home, at school — bullying, sometimes from abuse.”

People diagnosed with borderline personality disorder tend to report a history of abuse, neglect or prolonged separation as young children. Some studies show that as many as 70 percent of the people with the disorder reported being sexually abused.

Hoffman says people with BPD are born with an emotional vulnerability, so they tend to react more intensely and quickly and it takes them longer to cool down and return to a baseline of stability.

She compares it to someone with a hand wound trying to use the hand to pull a turkey out of the oven. “That wound is going to feel the heat more quickly. It is going to feel it more intensely, and when you take your hand out of the oven, the heat is going to remain longer on the wound,” she says.

DIAGNOSING THE DISORDER

Like in Green’s case, diagnosing BPD can be tough. The diagnosis can be time-consuming and people are often misdiagnosed with another disorder at first. It usually takes people in excess of five years before they are correctly diagnosed with borderline personality disorder, says Hoffman.

“Usually there is a pattern, and with a psychiatric diagnosis the symptoms have to exist for a period of time,” she says. For example, she adds, a parent might notice their adult child is moody and instable — spending a lot of money, unable to hold a job or changing jobs frequently. “There is a general instability, and a mood of up and down,” says Hoffman.

Complicating the diagnostic process is the fact that many people are misdiagnosed with other illnesses or have other illnesses on top of BPD. One recent study showed that about 50 percent of people diagnosed with bipolar disorder really have BPD, Hoffman notes.

Other studies show a correlation between BPD and post-traumatic stress disorder. It’s estimated that between 25 and 60 percent of patients with borderline personality disorder also have PTSD, a rate that is higher than the general population. Moreover, there are a few other related disorders — antisocial, narcissistic and histrionic — that are in the same cluster, as defined by the 4th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

Although all different, the four disorders share similarities that can cause confusion when being diagnosed. While BPD and antisocial personality disorder are similar to each other, people with BPD do not exhibit the criminal behaviors that are seen in people with antisocial personality disorder.

“They (people with BPD) tend to feel a lot of abandonment by others, while the person with antisocial behavior tends to be a loner,” says Coni Kalinowski, a psychiatrist with the University of Nevada School of Medicine who works out of the school’s mental health practice, Mojave Mental Health.

People with antisocial behavior connect with others to see what they can get out of them, while people with borderline personality disorder want to be connected with others and often get very anxious if they feel someone is leaving them.

“The borderline personality person seems to have very volatile emotions, lots of highs and lows, take a lot of risks, be suicidal and self-loathing,” says Kalinowski. “They may overdose, cut, carve themselves in various ways. They need to get back into their body and get a feeling of control.”

Follow the lives of today’s Hollywood starlets and you’ll see what BPD can do, Hoffman says. She declined to name names, but says she believes many of today’s troubled stars have borderline personality disorder. Many turn to self-medicating with alcohol and drugs to cope with the disorder, and that is what gets them in trouble.

“You never hear borderline, but for all of us in the field, that is the first thing we think of,” she says.

Compounding the problem, though, is that BPD rarely stands alone, says Hoffman. Eating disorders, major depression and anxiety disorders usually co-exist with the personality disorder.

To help facilitate and better diagnose people with personality disorders, the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders is being revamped. The proposed new guidelines, to be released in May 2013, will alter the definition of personality disorder. In addition, patients will also be assessed on how they match five types of personality disorders. Some personality disorders, like narcissistic and histrionic, that were previously recognized will be submerged into others.

Says Kalinowski: “In the DSM-IV, personality disorders were kind of defined as an enduring pattern of the experience of a person’s cognition, emotional make-up and personal functioning. There really wasn’t a lot of hardcore research that these are really entities and they didn’t really correlate with a lot of tools that are used to define personality disorders.”

Hopefully, she says, the new criteria will be more relevant to current research that is going on, and help answer the question of whether personality is a trait or a state.

TREATMENT: THERAPY OVER MEDICATION

Borderline personality disorder is the one psychiatric diagnosis where medication is not the number one treatment of choice, Hoffman says. Instead, what has been found to be most effective is dialectical behavioral therapy, a psychotherapy developed by Marsha M. Linehan, a University of Washington psychology researcher.

“It is a cognitive behavioral approach to treatment,” says Hoffman, adding that the idea behind dialectical therapy is that there is a behavior and the person wants to change it. “It is not so much about figuring out why you are doing that behavior; it is more about here is this behavior and what are you going to do about it.”

For Green, dialectical behavioral therapy was the answer to the years of suffering, both personally and in her relationships. She began attending a dialectical behavior therapy, or DBT, once per week. She also began visiting with a DBT therapist every other week and doing her own research on borderline personality disorder.

Green, who had already been certified as a life coach years before her treatment, decided to help others suffering from the disorder. After her diagnosis, she joined a local support group for family members of people with BPD.

“As I started to attend the meetings, the family members started to ask me about my experience so that they could understand their daughters and husbands and partners,” she says. “It was at that point that I knew that I wasn’t suppose to coach corporate execs.”

Instead, she says, she realized her life’s work was to coach family members to help them cope and be a better support, to coach people with BPD and to be a resource for them. She started the website, borderlinepersonalitysupport.com to reach others.

“I knew how hard it was to feel so misunderstood my whole life, and I wanted to put my name and face on a website, to come out of the closet so that others would feel that someone understood them — someone just like them,” she says, adding that she wanted people to see that someone with BPD can be normal, too. “It’s not your fault, I wanted them to know, and also I wanted them to know it was their responsibility to get better.”