Borderline Personality Disorder Counseling in Broken Arrow for Tulsa Area Residents

By Alina Morrow, LPC-S, CAMS II, GC, CCTP

Introduction: Personality Disorders in General:
(Understanding the Concept of Personality Disorder)

Borderline personality disorder is one of 10 different types of personality disorders, and is a pervasive and chronic psychological condition that affects the person's life. The personality disorders' group represents a distinct category among all psychological disorders that require sensitivity and skill when identified and diagnosed. When talking about personality disorders, two questions come to mind. What is personality and what is the fine line that distinguishes between what is considered "normal" personality and a personality disorder?

Personality as a word originates in the Latin term "persona" which means mask. Vastly defined, personality refers to a dynamic and organized set of thoughts, feelings, and behavior patterns that make up the uniqueness of one person. (1) It represents the stable way of viewing yourself, the world, and the interactions within the world. (5) "Personality arises from within the individual and remains fairly consistent throughout life." This consistency is evident through a recognizable order and regularity in the person's behavior.(1) A specific way of behaving becomes part of the personality (personality trait) when it occurs "in many times and places." (2) Furthermore, "personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts." (3)

Each person may act suspicious towards others, display paranoid behavior, become overly dramatic, too self-involved, or be reclusive at times for short periods and without significantly impairing the way they live their lives and work.(2) However, when this way of thinking, being, and behaving is extended over long periods of time and occurs in many situations causing significant distress and emotional pain for the people around them, and if the person cannot change this way of relating to the world and other people in order to improve their life and relationships - then that person might be suffering from a personality disorder. In other words, if these personality traits are inflexible and maladaptive causing significant functional impairment or subjective stress, the person is exhibiting a personality disorder.

The significant difference between normal personality traits and characteristics of a personality disorder can be conceptualized in terms of degree/dimension vs. kind/category.

There is an ongoing debate whether the distinct group of personality disorders should be seen in terms of dimension where the disorder is an "extreme version of otherwise normal personality variations" or in terms of category where a personality disorder is a way of relating that is different from "psychologically healthy behavior." (2) Today, the main diagnostic manual used in identifying and assigning a psychological disorder uses a categorical perspective in diagnosing personality disorders. Although designed to be convenient, it is also problematic because it over simplifies the subjective human experience. In the mental health field, the distinction between normality and abnormality is set according to what society decides that "a particular way of relating to the world has become a problem" and it is not as objectively identified as having a broken bone or infection. (2) Therefore, there are efforts conducted in replacing or supplementing the traditional diagnostic criteria with a dimensional model "in which the individuals would not only be given categorical diagnoses but also would be rated on a series of personality dimensions."(2)

A personality disorder is characterized by two dimensions: pervasiveness and inflexibility. The way the person views and project themselves tends to remain the same over time and across different situations. (5) In general, individuals suffering from a personality disorder possesses distinct psychological features such as disturbed self-image, inability to have successful interpersonal relationships, inappropriate range of emotion, ways of perceiving themselves, others, and the world, and difficulty processing proper impulse control.(4)
Due to these distinct characteristics, the individual exhibits a pervasive pattern of behaviors and inner experiences that differ from the norms of the individual's culture and therefore such behaviors "appear more dramatic than what society considers usual."(4)

Borderline Personality Disorder:

Borderline Personality Disorder is a chronic mental disorder that belongs to the distinct group of psychological conditions called personality disorders. The term "borderline" is consider to be a misnomer, as the name was generated sixty years ago when psychoanalysts theorized this illness as being on the border between neurosis and psychosis.(12) Although the present diagnostic criteria focuses on signs of emotional instability, feelings of depression and emptiness, identity and behavioral issues, and not on signs of neurosis or psychosis, the disorder maintains its name. In certain European countries, the disorder received a more appropriate and descriptive name and is being referred to as "emotional unstable personality disorder." (13)

According to the National Institute of Mental Health, borderline personality disorder is more common than schizophrenia or bipolar disorder. It is estimated to affect approximately 2 to 3 percent of the general population, 10 percent of all the individuals seen in outpatient mental health clinics, and 20 percent of the patients of psychiatric institutions. Among the total population diagnosed with one of the 10 personality disorders, 30 to 60 percent of these individuals have borderline personality disorder.(3)

In more specific terms, this disorder affects around 6 million Americans.(14) It is one of the most common personality disorders in a clinical setting. Related to gender, it is three times more common in women than men. However, the decreased prevalence of the disorder among male population might be explained by the reduced number of men that request help and address their psychological problems to mental health professionals.

History of the Borderline Personality Disorder Concept

Borderline personality disorder is a very controversial diagnosis, and over the years there were significant efforts to understand and bring this somewhat unstructured, amorphous concept into a concrete form. Some of the first acknowledgments of the disorder were documented by important ancient figures such as Homer, Hippocrates, and Aretaeus. Aretaeus described the condition as "the vacillating presence of impulsive anger, melancholia, and mania."(7)

After a subsiding period that lasted during the medieval era, the concept is revived by Bonet in 1684. He uses the folie maniaco-melancolique terminology to describe the erratic and unstable mood with periodic highs and lows that were not following a regular course. His observations where followed by other writers in the psychiatric field such as C. Hughes in 1884 and J.C. Rosse in 1980 who talked about similar patterns. In 1921, Kraepelin describes a "excitable personality" which closely resembles the borderline characteristics used to describe the present concept of the disorder.

The term borderline was first introduced by Adolf Stern in 1938. Stern wrote the first significant psychoanalytic work about borderline personality disorder and used the term "border line group" to refer to the group of patients exhibiting these symptoms.(8) Due to the intriguing symptoms of BPD, the condition was believed to be "a mild form of schizophrenia, on the borderline between neurosis and psychosis."(7) Stern's work was continued and advanced by the contribution of other mental health specialists. In the 1940s, Robert Knight introduced the term "ego psychology" into the description of the disorder.

This concept addresses the mental functions that enable a successful integration of the thoughts and feelings and the development of effective responses to the surrounding world. He suggested that individuals affected by this disorder have these mental functions impaired, therefore he named the condition "borderline state." (8)

Some of the other terms used to refer to borderline personality disorder between 1940 and 1950 included

• ambulatory schizophrenia,
• preschizophrenia,
• latent schizophrenia,
• pseudoneurotic schizophrenia, and
• schizotypical disorder.

Between 1960 and 1970 the understanding of this disorder shifts from being perceived as a borderline schizophrenia to being defined as a borderline affective disorder neighboring manic depression, cyclothymia (a condition characterized by mild hypomanic and depressive episodes), and dysthymia (a chronic mood disorder within the depression spectrum). Otto Kernberg proposed a new model of determining mental disorders by using three distinct personality organizations (psychotic, neurotic, and borderline personality). Another significant contribution was generated by John Gunderson who, in addition to writing about the disorder's characteristics, published a specific research instrument to enhance the accuracy of the diagnosis procedure. (8)

Borderline personality disorder was initially listed in DSM-II as Cyclothymic Personality due to its affective components. For a brief period of time some psychoanalysts used this disorder as a "wastebasket diagnosis" due to its overlap with so many other psychological disorders but also to help classify patients that did not fit in other diagnosis categories. The disorder was listed as a personality disorder for the first time in DSM-III in 1980 and the diagnosis was formulated in terms of affects and behaviors. (7)

Borderline Personality Disorder Signs & Symptoms

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), borderline personalit disorder is defined as "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity." (3) As the definition suggests, the one word that best describes the disorder is instability.

Unstable Moods and Emotions: Individuals with BPD display unstable emotions with wild fluctuations triggered by no reasonable causes. Due to their difficulty of stabilizing their moods, it is common for these individuals to have erratic emotions with intense episodes of anger, emotional anguish and depression, irritability, and anxiety that can last between a few hours to a few days. Episodes of anger are usually intense, inappropriate, and difficult to control.(8) These individuals lack the normal ability to tolerate anxiety, frustration, loss, and rejection, and to find comfort when upset.

Depression: Depression is another common symptom among individuals with BPD, and it usually manifests as episodes of major depression. Although feeling depressed these individuals differ from those suffering from chronic depression, as the BPD depression is qualitatively different. Borderline personality disorder depression is "much more susceptible to change in response to external events," the person experiences less guilt, appetite loss and lethargy, but they have chronic feelings of emptiness, loneliness, and boredom.(9)

Unstable Behavior: In addition to affective instability, individuals with BPD display unstable behavior. They can alternate between periods of "excellent conduct, high efficiency and trustworthiness" to "outbreaks of babyishness, suddenly quitting a job, withdrawing into isolation, failing."

Self-Damaging Behaviors: Other behavioral manifestations of the disorder include self-damaging acts (excessive spending, unsafe and inappropriate sexual behavior, substance abuse, reckless driving, binge eating, cutting, burning, and punching themselves ) and "recurrent suicidal behavior, gestures, threats, or self-injurious behavior." (8) Self-damaging behaviors can be triggered by threats of separation from others, by rejection, and by demands of parenting or intimacy, or can occur during dissociated states. In such moments, these type of behaviors help the individual feel real and even stop the anxiety episode while purging feelings of badness. Although dangerous, these behaviors mostly cause great distress but in essence they lack "the intent to severely harm" the person.(9)

Over-Impulsive: Another significant symptom displayed by individuals with BPD is impulsivity. Some physicians consider that this disorder should be included in the spectrum of impulse control disorders together with antisocial personality disorder, intermittent explosive disorder, and pathological gambling. Impulsivity negatively manifests itself in different aspects of the person's life. It can be observed at the behavioral level when the individual engages in self-destructive acts, aggression and violence, and suicidal behaviors. (9) Impulsivity affects emotions and these individuals outbursts in episodes of negative emotions and lack the ability to control a rageful state of mind. (8).

Negative Impact on Relationships: Instability affects the person's interpersonal relationships and patterns of establishing relationships.

• Individuals with BPD can fall in and out of love suddenly, idealize others in order to abruptly despite them.
• They develop stormy attachments (they get attached to and immediately idealize other people) but rapidly turn from idealizing to devaluating family members, friends, or significant people in their life at minor signs of separation or conflict.
• They are extremely sensitive to rejection or separation (even in mild cases of separation such as a vacation, trip, or sudden change in plans) and respond with anger and distress even accusing the other person of not caring.
• These individuals fear abandonment which leads to difficulties of feeling emotionally connected with significant people in their life when they are physically separated.
• When feeling abandoned or disappointed, the individual can threaten or even attempt to commit suicide. (6)

This unstable behavior and emotional state creates significant difficulty for the family and close associates of an individual with BPD as they don't know what to expect from them. Living with such a volatile individual that produces - angry outbursts, impulsiveness, self-mutilation, attempted and threatened suicide - creates an acute feeling of chaos and inability to help for those around. (11)

Identity Issues: Individuals with BPD have distorted cognition and have difficulties in maintaining a stable, consistent sense of self. They display identity disturbances that can include feeling like they don't know who they are or what they believe in, feeling "non-existent," or having a chameleon identity based on circumstance or what they think people want from them.

These identity issues affect their interactions with others as they struggle with determining who they are in a relationship with others and in some cases having difficulties understanding where they "end" and the other person "starts." This creates difficulty in establishing and respecting healthy boundaries.(15)

• It is common for these individuals to perceive themselves as fundamentally bad or unworthy. (6)
• They can drastically and rapidly make changes in how they perceive what they like/dislike, strength and weaknesses, goals, and personal value. (10)
• Black-and-white type of thinking is common among individuals with BPD.
• They also frequently change long-term goals, career plans, jobs, friendships, gender identity, or values. (6)

Unfortunately, this condition has profound impact on the life of the person by losing jobs, spoiling opportunities of success, shattering relationship, alienating family and friends.(11)

Borderline Personality Disorder Causes and Risk Factors

The development of a borderline personality disorder (BPD) is a complex phenomenon that is not clearly understood. Although the exact causes of this disorder are still unknown, there is significant effort and research being conducted to identify and understand possible factors that contribute to the development of this condition. As for many other psychological problems, there is a mutual consent among scientist that BPD is caused by a combination of factors (biological/genetic, and environmental/psychological).

Environmental Factors: There is a strong link between the development of BPD and "environmentally mediated aversive events" such as distressing childhood experiences particularly involving caregivers.(14,16) Some of the distressing experiences that have been associated with BPD include but are not limited to include: physical and sexual abuse, early separation from caregivers, emotional or physical neglect, emotional abuse, and parental insensitivity. Marsha Linehan who designed the dialectic behavioral therapy (DBT) for individuals with BPD talks about an "invalidating environment."

This environment was described by experiences and situations when the child's beliefs, thoughts, preferences, discomfort, and emotions are not taken seriously and properly addressed, therefore these experiences are not validated and their emotions seen as not important. For example, if the child complains that he is hungry the parents might answer he can't be hungry because he just ate. A similar situation would be when the child expresses upset feelings, while his parents don't pay attention to his emotional state and even accuse him of making a big deal out of it. The child can even be blamed and trivialized for his painful experiences. Their behavior is usually controlled through punishment that spans from criticism to physical and sexual abuse.(16)

In 1988, Kroll suggested the BPD symptoms are very similar to those of post-traumatic stress disorder. There is evidence that traumatic events or experiences during childhood (especially when the brain is not fully developed) affects its chemistry and decreases the person's ability to deal with stressful situations later in life. In 1996, a number of researchers (Perry, Pollard, Blakley, Baker, and Vigilante) described the impact and effect of early trauma on the child's brain. In the presence of a threat, the hyper-arousal response is activated in certain area of the brain, areas that "play a critical role in regulating arousal, vigilance, affect, behavioral irritation, locomotion, attention, the response to stress, sleep, and the startle response..."(14)

The threat-induced hyper-arousal response is normally activated only in the presence of the threat stimulus, to a specific reminder of previous trauma, or thinking and/or dreaming about the traumatic event. Initially, the "stress-response apparatus" is being activated by the presence of the threat stimulus and in time can be triggered by specific reminders which can be very generalized.

These scientists also suggest that the human brain during early childhood stages of development require and is more sensitive to "...certain types of organizing experiences" that "literally format some of the child's developing brain structures and functions. [...] Trauma, occurring during critical/sensitive periods, is an experience that is capable of affecting the organizational development of the brain." (14) According to their explanation, the "more frequent, intense, and persistent the traumatization, the more the brain's systems associated with fear are activated. Such frequent activation 'builds in' a chronic state of fear for the child." (14)

According to numerous studies there is a strong association between BPD and pyschotraumatization during childhood. Herman, Perry, and van der Kolk (1989) show that traumatization rates for individuals with BPD range from 71 percent were physically abused, 67 percent were sexually abuse, and 62 percent had witnessed domestic violence. A study conducted in 1994 by Paris, Zweig-Frank, and Guzder concluded that trauma and problems with fathers are important factors in the development of BPD in males. According to a study published in 1991 by Runeson and Beskow, individuals with BPD that committed suicide showed more parental absence and substance abuse in the home.(14)

Biological Factors: Although early studies gave evidence that borderline personality disorder tends to run in the family, they were unable to determine what caused family members of individuals with BPD to be prone to develop this condition. The contemporary advanced technology and research methodology have allowed scientists to work towards identifying the biochemical infrastructure of the disorder which leads to a better understanding of the condition. The new discoveries also help physicians look at the disorder from a different perspective. Based on this new information, there are voices that claim that BPD is not a 'flawed personality' but rather a biologically based brain disorder. (17)

One of the discoveries that reveal a biological vulnerability for BPD identified a link between this condition and a limbic system dysfunction. The limbic system is known as "the emotional center of the brain."(17) Two of the important components of this system, amygdala and hippocampus, play a significant role in regulating emotional expression (especially emotions such as fear and rage), the automatic reactions (such as impulsive behaviors), and emotional memory. It was discovered that individuals with BPD have a smaller volume of the hippocampus (16 percent smaller) and amygdala (7.5 percent smaller) than those without any mental illness.(17)

Also, the amygdala is an important component in the circuit that regulates negative emotions, and it is the one that marshals the fear and arousal response in the presence of threat. The activity of this circuit is also influenced by the activity of the frontal lobes.(6) With the help of positron emission tomography scan (PET), scientists were able to discover that individuals with BPD exhibit a lower level of brain activity in the pre-frontal cortex caused by a reduced level of glucose. The pre-frontal cortex regulates emotions usually by inhibiting activity therefore offering a better control and ability to suppress negative emotions. The pre-frontal cortex, together with the ventral medial pre-frontal cortex and anterior cingulate cortex, also plays a significant role in inhibiting parts of the limbic system involved in generating aggression.

"From an evolutionary perspective, aggression is a response to a potential threat or provocation across a variety of species and seems to be an inborn response tendency." During evolution, the human beings developed "higher-order cortical centers" that suppress primitive forms of aggression when they are not appropriate.(20)

Low levels of glucose has been connected to deficiencies in serotonin production. Serotonin is one of the neurotransmitters that facilitate the regulation of emotions such as sadness, anger, anxiety, irritability.(6)

Scientists looked at the serotonin activity in the brain of individuals diagnosed with BPD and observed a lower 5-HT function (serotonin 5-hydroxytryptamine - the pharmacological term for serotonin). This study also related reduced 5-HT functioning with a history of suicide and/or aggressive behaviors. Although these results are preliminary and additional research is needed, identifying a possible link between impulsivity and serotonin levels will generate new perspective in the pharmacological treatment of BPD.

In addition, studies conducted on examining the role of serotonergic agonists such as fenfluramine (which causes the release of serotonin, blockade of reuptake and direct agonism of 5-HT2 receptors) resulted in blunted prolactin (peptide hormone) responses in individuals with BPD. Blunted hormone responses to fenfluramine was also observed in individuals with major affective disorders. (20)

Studies conducted on the metabolism of catecholamine in BPD individuals is similar with that of individuals suffering from PTSD (post-traumatic stress disorder) which explains the role of early stress and trauma in the etiology of BPD symptoms. Catecholamines are the 'fight-or-flight' hormones that are being released in the brain in conditions of stress. Reduced presynaptic concentrations of such hormones might be responsible with exaggerated irritability in response to stress. (20)

According to a recent study conducted by a researcher from the University of Missouri and a Dutch team of researchers and published in 2008, "...found that genetic material found on chromosome nine was linked to BPD features" at marker D9S286. (18)

Although such discoveries are in the initial stage and the genetic picture of the disorder is still not understood, their contribution to the understanding of the disorder are undoubtable. An important aspect for individuals with BPD is the inability to manage emotions, but it is becoming more and more obvious that while environmental factors can trigger the development of the disorder the "genetic-neurologic link is the switching on and off of genes that produce and modulate the brain's response to neurotransmitters." (19)

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Do you have borderline personality disorder and want to get help? Contact Tulsa Therapist Alina Morrow, LPC-S, today to make an appointment and get the help and relief you deserve. You can reach me by texting or calling 918-403-8873 or by Email.

Page Last Updated: July 24, 2022