Sunday, May 18, 2008

Over The Border Line

A podcast listener asked us to talk about managing patients with Borderline Personality Disorder. Ugh. I don't want to talk about it.

Instead, I'm going to talk about why I hate the term, why I rarely place it in writing, why I wish it would go away.

Okay, the diagnosis of Borderline Personality Disorder is probably a perfectly valid diagnosis. If you read Roy's post about the differential diagnosis of Chloe O'Brians Personality Disorder (from 24), you'll see the following diagnostic criteria:

A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, with many of the following features:
1. Frantic efforts to avoid real or imagined abandonment such as lying, stealing, temper tantrums, etc.. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, substance abuse, reckless driving, overspending, stealing, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. 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).
7. Chronic feelings of emptiness, worthlessness.
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights, getting mad over something small).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

I mean, okay, these symptoms cluster in some people, so why don't I like them?
Here goes, with no particular rhyme or reason:

  • The diagnosis (unlike, say, Trichotillomania or Major Depression) is pejorative.
  • Clinicians are sloppy with the diagnosis and it's not uncommon for a doc to refer to a patient as "a borderline" as a defense--- the patient is difficult to deal with, he's angry or demanding--it's gotta be him, not the doc.
  • It's what clinicians label patients they don't like.
  • Actually, men are almost never called "borderline"....they get to be narcissistic or antisocial.
  • Treatment-wise, many docs avoid these patients and hope runs dry quickly. The prognostic implications are generally not great, these patient don't have rapid and dramatic improvements.
  • The diagnosis ends up being it's own endpoint, it doesn't leave room for alternate explanations and sometimes patients with Bipolar Disorder look a lot like patients with borderline personality disorder. Oh, while I'm there, patients with Borderline Personality Disorder often have co-morbid Bipolar Disorder (and hey, how about some substance abuse issues thrown in) and if the clinician can get focused on treating the Mood Disorder, sometimes the other noise fades into the background.
  • It doesn't seem to me that every patient who has these symptoms has them forever in an inflexible way. They come, they go, they change, they get better, they get worse.
Okay, so there are those people who tend to live life feeling victimized, who see things in black and white, who cut themselves to ease their pain, who can't maintain relationships, who create drama wherever they go.... I guess we're left to call them Borderlines.


Midwife with a Knife said...

Hm..... I agree. It does seem odd that a diagnosis is so perjorative. And... only in the personality disorders does that happen (although fibromyalgia is getting there).

Also, if a patient has Major Depression or postpartum depression, I have some idea of some things that will help (mostly my armementarium consists of SSRIs and referrals)... but a borderline patient? Or any other personality disorder, for that reason.... I have no idea where to start, and they are difficult patients to referr, because so often, what we get told in the consult notes is, "She has borderline personality... nothing we can do." It really seems bad that there's nothing that can be done for those people, because they are in real pain. Their behavior (which is part of their problem) just happens to be highly annoying and difficult.

Also, there is a very fine line between a personality disorder and a personality flaw. Some people are narcicists and get along just fine in life, and while they bug the rest of us, maybe they're happy. And what about those antisocial personality people? Maybe not really having empathy really works for them. And even if they end up in jail... 3 hots and a cot.

It may be a little different, because I have met(apparently) happy narcisicists and (apparently) happy antisocial people, I have never met a (even if only apparently) happy borderline. Sure, their lives aren't what I'd want, and they're annoying, but they a lot of non-borderlines seem to do ok for life-satisfaction.

I could be completely off-base.

Cobweb said...

I've been in therapy a lot over the course of my life - I've been struggling with resistant major depression (finally tried lithium this year - whew) since grade school, and had a turbulent upbringing. Once I went inpatient during a particularly rough patch, and after an experience with the hell on Earth (for me) that was Paxil and the resulting withdrawal, I wasn't willing to try any antidepressants. I was adamant, and ended up locked in a power struggle with my assigned psychiatrist (in his residency). On my last day there, he flippantly said "I'm putting borderline on your chart, too." I didn't know what that was, and when I went home and Googled it and read some patient forums, and worse yet some therapist forums, I was horrified. I was scared to ask for help from anyone for a long time.
That was seven years ago, and I still struggle with that sometimes in therapy, even though no other clinician I've seen has ever confirmed it. The stigma around it is palpable, and if I'm feeling abandoned in my marriage (separation in progress), I'll cast around frantically for another word, to avoid being seen as having a fear of abandonment. If that psychiatrist wanted to take a swipe at me for being a difficult patient at the time, he certainly succeeded.
I've taken to calling it 21st century hysteria, because that is how it seems to be used.
I may have had a point in sharing that, though I'm sure any responsible clinician is well aware of the power of their words.

Anonymous said...

My psychiatrist "diagnosed" my SISTER as "Borderline" from my description. She's been repeatedly abusive to me & she flips in an instant from conversational to a red-faced screamer who won't stop screaming at me. It really does not matter whether she is curable or incurable or if the label is fair or unfair. It's accurate in the way that SHE TREATS ME. She's not seeking help. I am. The Borderline label reminds me of why I avoid her.

Awake and Dreaming said...

social workers totally have borderline stigma down to a science. i swear, every work shop I go to someone says something about "well what about borderlines". I had a client, they fudged an axis one diagnosis to get him into our program, but he was very axis two, which we weren't as set up for. drove us crazy... what did we blame? the fact that no one warned up about the personality disorder, why would they though, he actually is good for the program and we wouldn't have taken him if we'd known.

There was a time I was convinced I was borderline...the fact that I was still a teenager, totally explains it. But, something I have found helpful was to think in terms of the clusters of personality disorder traits and to notice them in myself and others.

For example, I have cluster (c, i think) traits which are the borderline, histrionic, dependent ones. They come out most when I'm stressed or upset. Learning more about them has created self awareness which has lead to healing.

Anonymous said...

BTW I would like to point out that not everyone who self-harms and is a female under 30 is a borderline.

It's far too common for a woman to be given this diagnosis because she is depressed and also self-harms. Lots of depressed people self-harm due to the depression.

shraddha said...

You are talking like such a typical Psychiatrist.I have heard this! That using Axis 2 diagnosis is a matter of hesistation to many!

Anonymous said...

I was really encouraged by reading this post. I am glad there are psychiatrists who are thinking about the ramifications of this diagnosis on the patient. If someone is diagnosed w/ BPD they will be prevented from entering certain professions and once it's a part of the medical record it doesn't go away.

My purpose for seeking out therapy was to improve my life not make things worse. Did I have pretty ineffective ways of coping? Yes, that's why I entered therapy. But, saddling me w/ a personality disorder diagnosis would not have been remotely helpful to me & would have left me feeling pretty hopeless. I needed to be able to get well and move forward, and with my therapist's help - that's exactly what happened.

If I were to ever need therapy again in the future I would avoid someone who listed themselves as specializing in personality disorders. For me, what was helpful was learning different, more effective ways of coping in a way that did not pathologize me as a person. If I want to be an attorney someday or enter the medical field, I can do it because I don't have some label following me for the remainder of my life.

Dr. Pink Freud said...

Maybe we should come up with a better name for it, say, "Really Annoying Patient D/O", or "Patient I will soon refer to someone I don't like D/O."

Anonymous said...

I think Dr. Pink Freud beautifully illustrates why this diagnosis is going to be oh so helpful to the patient. If you find you hate one of your patients here's an idea - how about you refer them & stop taking their money.

Anonymous said...

I think that people end up with what we call personality disorders when, during their growth as people, they get developmentally blocked/scarred. I liken this to a plant that does not receive the proper light, space to grow, and/or nutrients at the right time in its growth cycle. When that plant is an "adult" plant, it will show the scars of this deprivation (pardon my mixed metaphor.)
In the same way, a person not provided with the right ingredients during growth, could develop a set of scars that, by convention, the mental health profession calls "personality disorder" or "borderline personality disorder." I don't think it is a pejorative term in and of itself. But, unfortunately, in the same way that mental illness is stigmatized within general medicine, borderline is stigmatized within mental illness (doubly stigmatized.) I wish, of course, that mental illness and borderline was not stigmatized at all. I try to see all diagnoses with neutrality (lack of judgment) and compassion (because all of us people with mental illness do suffer.)

Dragonfly said...

Yeah...Like is a personality disorder a mental illness? Or (as MWWAK said) a flaw. Or simply a variant of normal (like the argument about autism as neurodiversity).
I heard an emergency physician once define personality disorders as "people you want to punch 5 minutes after you meet them". I thought that was a terrible attitude (and showed a certain lack of psychiatric knowledge, as well as other things). Which was an extreme example of the perjorative nature of this diagnosis, and the widespread ignorance and prejudice regarding this.

Anonymous said...

Dragonfly: If you're personality prevents you from making any friends, working a job, having a family, and leaves you with self-injurious &/or life threatening behaviors and you're miserable all the time, then yup, it's a mental illness. I don't think many people have borderline personality disorder who have not also, at some point, had an episode of a mood disorder, and it helps to treat the mood disorder (and not to shrug it off to the affective instability of the personality disorder).

There may be mildly autistic people ("on the spectrum") who some might consider to be normal, but some are clearly disordered, in need of diagnosis/treatment/management.

An ER is a particularly bad place to diagnose personality disorders--- people come in acutely ill, in pain, in crisis, if they're in the psych ER they may have been dragged there by the police-- it's a setting where people with perfectly fine personalities can present agitated, distressed, irritable, sick, delirious, vulnerable, or feeling violated. One might hope for a little more compassion from an ER doc. It's like judging someone based on the curses they utter while in the throes of labor.


Alison Cummins said...

[Warning: lots of rambling thoughts follow with no particular point.]

I actually kind of like the “people you want to punch five minutes after you meet them” quick-and-dirty diagnostic for personality. It’s a parallel with the diagnostic for depression which is “people who depress you.”

Someone with a personality disorder isn’t usually out of touch with reality. They aren’t hallucinating. They just don’t interact with other people in ways that other people consider useful.

One account of borderline personality disorder is that it’s what happens when the brain compartmentalises pleasant or neutral memories in one hemisphere of the brain and unpleasant memories in the other. And that it’s what happens when children are raised in stressful environments. Now, think of raising a child in the midst of war (pretty stressful; and small communities with constant raiding have probably been typical of much of human evolution). Wouldn’t you want your child to use black-and-white thinking to distinguish between family and enemy? And wouldn’t it be useful to be able to close ranks quickly against allies who had betrayed you, or to form an alliance with enemies from the past when the situation changes? Borderline personality disorder may actually be a normal variant of human functioning that displays its usefulness in times of war. In times of peace, when we need to be able to trust strangers to conduct business with them, it’s not so useful. (Going around trusting strangers and trying to do business with them could get you killed in wartime. You might get labelled with "naive and gullible personality disorder" before you died, and there might be considerable resources devoted to treating this life-threatening condition. Or you might just be eliminated early on as being a loose cannon and a threat to the group.)

Or antisocial personality disorder. It’s actually quite good for an individual if there aren’t too many of you. You can ride roughshod over a community of nice, cooperative people and take everything they have. Clearly a normal variant that has evolved as being genetically fit... but only if there aren’t too many. If there are a lot of you, then the nice people stop cooperating with anyone, including eachother, and the community as a whole suffers. There’s less to take and what is left is harder to get at.

With this kind of analysis, a person with a personality disorder is not ill, just mismatched or disliked. That doesn’t make them happy or productive, but it makes the mental illness paradigm difficult to apply and the concept of treatment questionable.

Dinah, how do you “treat” autism? With antibiotics? Chelation? Special diets? Psychoanalysis? Forty hours a week of ABA? Parents attempting to cure their children of autism have caused a great deal of unproductive suffering.

Michelle Dawson can’t cook without endangering her life: she’s very autistic. She’s also a scientist. Amanda Baggs has enabled herself to focus on her work by eliminating distracting activities from her life — like walking, talking and trying to figure out when and where it’s socially acceptable to poop. She’s very autistic. She’s also an articulate activist and has published some thought-provoking videos. Clearly these two people need the cooperation of people in their communities to function. But when they have it they are productive and as happy as anyone else. And they don’t believe their autism is something to be “treated.” They feel it’s part of who they are, which is an extreme variant of normal. Like any extreme variant, they need special accommodation from a society built around more typical people. Being autistic also means they see things that NTs don’t (literally: there are visual tests for autism where if you can see the pattern you are autistic and if it’s a jumbled mess you are neurotypical) and they have something particular to contribute.

I see autism quite differently from personality disorder in this sense. Michelle Dawson is much happier working as part of Dr Laurent Mottron’s research team at the University of Montreal than she was as a letter carrier, and this works out better for all of us. But someone with antisocial personality disorder might be really happy scamming old people out of their life savings, and the rest of us are not better off for it.

Alison Cummins said...

More rambling thoughts...

Treating autism.

Usually what people mean by that is teaching autistics to behave less autistically. For instance, teaching a child not to rock, but to sit still. They might not think as well when they are sitting still — they might rock as a way to generate white noise so they can figure things out — but they look less autistic so the rest of us are more comfortable. Or teaching a child to use spoken words instead of a bliss board or a speech synthesiser. Us NTs (neurotypicals) are much more comfortable with direct spoken language than with use of an intermediate method, but an autistic person might communicate better manipulating external symbols than having to focus on modulating breathing, vocalisations and all those oral contortions as well as developing their thoughts all at the same time.

If you “treat” autism by teaching an autistic person to behave like an NT, you may be missing out on some of the things they have to contribute and you are not necessarily helping them to develop their full potential.

That doesn’t mean neglect. Temple Grandin points out that she was able to accomplish so much because someone developed her interests. She wouldn’t have ended up earning a PhD if she had been left alone to play with string.

Helping a person learn to be the best they can be doesn’t have to be called treatment or therapy either. For NTs we just call it child-rearing and education. Why call it “treating autism” or “therapy for autism” just because it’s sensitive to the particular needs of someone with, for instance, sensory integration issues?

On therapy:

On what it can be like to be a high-functioning autistic:

(So what would “treating” Joel involve? Signing him up for Meals on Wheels? That might be a treatment for hunger, but hardly for autism. It might even be considered enabling autism!)

A friend with arthrogryposis commented once on all the effort that people put into inventing various mechanical arms that disabled people can use to pick up their pens from the floor when they drop them. “Wouldn’t it just be easier to teach able-bodied people to be polite and to lean over and pick up the pen?”

Dr. Pink Freud said...
This comment has been removed by the author.
Dr. Pink Freud said...

Lest I be misunderstood, a few words of clarification. My comment was meant to point out the negative association with the Borderline Dx. (with intended sarcasm; my personal favorite defense mechanism ;-), not to devalue patients who suffer from it.

Although the challenge of working with patients who have a Cluster B Dx. can be intellectually fulfilling, the "symptoms" (or perhaps some would prefer "maladaptive coping patterns") that characterize the patient suffering from Borderline Personality D/O can make Tx. extremely difficult and the return on investment for both patient and clinician is often perceived on both sides as minimal. I suspect this is why many clinicians "patient dump" these individuals.

Working in a prison setting, I eat, sleep and breathe Antisocial Personality D/O, with the occasional Borderline patient mixed in, and believe me, Borderlines in correctional settings are generally scary folks with which to deal. (Inevitably, there's more Cluster B stuff going on than just the primary Dx.) For me, it's enjoyable work, because I define my success in therapy in a way that may clinicians don't. I look for small change. I'm not expecting to "cure" anybody, and in my experience, it's the small, though meaningful change that can be the most lasting. To quote "What About Bob" (a must see for clinicians and patients), it's about "baby steps."

ClinkShrink said...

Alison: Great comment and I enjoyed reading your theory on the adaptive aspects of borderline personality disorder. I had often thought about the evolutionary benefits of antisocial personality disorder, but never about that aspect of BPD. Interesting. Thanks.

Pink: I know exactly what you're talking about. It only takes one or two inmates with severe borderline personality disorder to throw an entire institution into turmoil. Unfortunately, they never come in to the facility in groups as small as one or two.

Dinah said...

Just a quick clarification of an earlier comment I made:

I was addressing a comment made by Dragonfly and said "If your personality prevents you...." I meant "you" as a generic "person" not as a comment directed at Dragonfly personally.

Roy saw this and thought it could be construed as a direct and personal comment on Dragonfly's personality-- not intended that way at all, but I figured if Roy thought that, then someone else might as well.

I still don't like the idea of a 5 minute diagnosis under extreme conditions.

Anonymous said...

If you have not, then you might want to read Judith Herman: Trauma and Recovery. Herman believes that the BPD should be reframed as post traumatic stress disorder. This is, I believe, part of what Alison was saying. This also takes the blame off the patient and helps the clinician understand what it might be like to be this person rather than seeing them as a constellation of icky symptoms and calling them borderline, which is a door to nowhere. It doesn't matter whether or not one believes PTSD is also overdiagnosed. Probably eveything is.It does help to reconceptualize the whole BPD diagnosis since almost eveyone seems to agree it is a wastebasket diagnosis.

Mary said...

I'm a psychiatric social worker, and I agree that BPD is often conflated with Bipolar Disorder. The labile emotions are similar. Personally, I believe that women who have PTSD from rape, childhood abuse and other trauma are misdiagnosed with Borderline frequently. It is very much simply a clinical way to say "I don't like this patient."

Similarly, I think that many African American (especially) men with PTSD are misdiagnosed as antisociaL. That's another diagnosis that is severely stigmatized. Often it is a clinical way to say, "This person frightens me."

Even the nicest psychiatrist at my agency hates people wth BPD. She's downright mean to these people and refuses to prescribe medication for their Axis I comorbid illnesses. She tells them that she won't do anything for them and they should go to DBT classes and therapy to get over it.

Alison Cummins said...

Thanks, clinkshrink.

The depressing part about my conjecture (I wouldn't go so far as to call it a theory) is that it suggests that once conflict starts in a community then it affects the brain development of the children growing up in it... making peace and positive change for the community difficult.

Alison Cummins said...

Dinah, RE judging people in the ER:

From what I've been reading in medblogs lately, the ER is not full of trauma patients. It's full of what many ER workers not-so-fondly refer to as "entitlement syndrome." (From my seat far, far away the "entitled" people "abusing" EMTALA in ERs all over the US appear to be largely members of an underclass, which is not the population to who I am used to applying the descriptor "entitled," but there you go.)

From what I can gather, the people this ER doc wants to punch are probably the ones who take an ambulance in for their 10/10 tooth pain, and when triaged to the waiting room demand food from the staff and talk on their cell phones (not at all like someone with 10/10 tooth pain) and when they don't get everything they are asking for when they ask for it start accusing the staff of racism, sexual assault, malpractice etc. And when they are denied opioids on they grounds that they have been to the ER for their 10/10 pain every day for the past two months, likewise to all other ERs in the area, and have already filled two Dilaudid prescriptions that day, they become furious and combative at being accused of lying.

I mean, this may not be the borderline personality that this ER doc was thinking of, but that's a caricature/composite of one type of person ER nurses and docs all across the American blogosphere are complaining about having to deal with. There are many others; the fibromyalgia patient who insists on getting regular intensive workups in the ER rather than being followed by a rheumatologist in clinic is another. The point being that an ER is full of people with difficult personal needs, many of whom are not being seen in the trauma bay or the cath lab because they are not currently having a physical emergency.

I am guessing that the ER doc was thinking about some of these people with other needs, not the truly emergent that they wish they were seeing. ER bloggers tend to be (or portray themselves as) pretty tolerant of most trauma patients, no matter how drunk, because it's obvious that they belong in an ER. They understand their own role and the role of the patient.

Alison Cummins said...

... and most importantly, they can provide what is being asked of them.

Sarebear said...

It actually took me about 7 or 8 months after I started cutting (it was about 4-7 weeks into therapy, right after I started - what was I, 32? 33? I forget . . . . not your typical first-timer for that sort of thing), to realize that it would instantly put me into a stigma-filled category in many mental health "professsionals'" minds. I put that in quotes, because if they were professional, the problem wouldn't be so widespread. It's a problem far too widespread throughout the mental health system, and I was shocked when I realized that I'd be so easily "labeled and dismissed" really . . . . even though this self-injurious behavior started after thirty, and I was the "good" child/teen/young adult, and I wasn't short of friends because of drama during those ages, but because I'm plain-looking, and when younger people pick on those - as a teen people may not be so in your face about it, but you aren't in with anyone, and you can't GET in with anyone. It's not because of drama, or anger, or personality issues. You are just quietly by yourself, because that is what is left for you to do and be.

Anyway, the fact that the professionals will so quickly just sweep people into this dustbin label, that they'll be so judgemental about it - that these professions, where they've been trained to supposedly be MORE understanding and LESS judgemental (yeah, everybody's human, yep!) . . . . it just bugs the hell out of me!

As you may see in one of my long comments on another recent post, of course there is much about my developmental history that DOES fit, which is probably why I've been told I've got "elements" (by my kind psychologist; my first psychiatrist actually ended up shoving me into the dustbin of borderline, actually, later in our relationship, because he didn't LISTEN to ME, he didn't HEAR ME, he didn't HEAR what I was COMMUNICATING, he HEARD what he was LOOKING for, if that makes any sense . . . . ), but I'm glad I'm not a raging angry user manipulater fighter provoker what have you. I guess that may be stereotyping the worst of some aspects of some disordered behaviors of some disordered personalities or types or whatever, I'm not sure of the proper terminology . . . .

Anonymous said...

I didn't know people hate us so much. I've been doing really well, but recently I saw the word "borderline" in my chart and after reading all this, this makes me upset. Ironically this makes me wish I could die again, which is totally not normal.

I haven't OD in a long time, years. I haven't been fixating on death, but I still get triggered sometimes.

Reading this blog upset me. I want the dx erased from my records. This sucks.

(Hello there, this is Deneb, I just found this blog, I probably won't read it regularly tho, I was at the APA, the second presenter, just wanted to say Hi)

Repat said...

I think this is a fantastic post, and it is refreshing to find a shrink with this perspective. I was in NYC some months ago, at a literary reading. A friend of a friend was there, happened to be studying with Kernberg (serious hero-worship happening) at the time. After the reading, this shrink-in-training refers to one of the writers (the female one, natch) as "clearly borderline." Huh? Did we need a diagnosis? Annoyed, I politely asked why he thought so. "I saw her novel. It's all about split personalities--very borderline. And she has piercings all over her face, and a tattoo."

I was so so annoyed but let it go, since it was a mixed crowd. It just seemed so typical of the way the term is used to be reductive and dismissive, especially of young complicated women. And in this case, the woman wasn't even "sick". It was so much more about the student needing to categorize (and, I'd guess, minimize) people who were a bit unconvential. He didn't seem to notice that she was a talented artist, or that art might exist beyond/separate from pathology. The whole thing made ME sick.

Anyway, thanks for the great post.

Anonymous said...

Note to therapy patient and others in the same shoes:

It seems more than questionable to me to read someone's "inner defenses" at a distance and interpret any manifestations of anger in young women as "borderline". Apart from the fact that probably up to a third of those with BPD internalize their anger, which makes them invisible today, but they suffer just as much if not more. It's just these kind of quick irresponsible judgments that stereotype this disorder and transform it into a trashcan dx.

If you are in therapy and someone tells you your sister is borderline, if this dx is true - than in an ideal world this should help you understand that 1)your sister is in an unbelievable amount of psychic pain when the anger surges through
2) she most likely feels terribly guilty afterwards, but her SELF is so fragile that if she cannot turn this anger outwards she risks to turn it inwards and suicide then becomes a very real possibility 3)she is most probably depressed and depression alters one's emotions and sensibility...4) she battles with a terrible self image tainted by shame, guilt, fear, conviction that no one could love her, etc. 5)her damaged and mortified sense of SELF can no longer handle any negative criticism from the outside, if any (she'll turn it into a hundredfold accusatory inner voices) - she desperately needs to hear what is okay about her, to learn that she too can be likeable, to hear that she too is a real person who has a right to her reasons...

Admittedly under such an intense assault no one is going to do more than defend themselves, but
why not ask yourself what could be triggering this - why does she feel the way she does - for "BPD anger" usually is often the end result of many years of keeping one's normal feelings of hostility pent up. It may also be the result of serious trauma and abuse that she is hiding, of a serious developmental disorder that she never asked for (like autism or ADHD), (she never asked for BPD problems either - no one would ever choose this kind of Hell), there might be partial seizures, other neurological damage, chronic debilitating insomnia, PTSD, bipolar disorder, anger as a "narcissist" , "paranoid" or "schizoid" defenses rather than being a "borderline" emotional dysregulation problem ...Not incompatible with any of this is the presence of a very dangerous, suicidal, clinical irritable-hostile major depression.

The bottom line is that this kind of anger shows up in many many situations. Studies have shown the people with BPD do not get angry any more often than most people - they just spiral down into a morass of negativity when they do and have an enormous time getting out of their negative moods - although they are suffering terribly and do not consider them "syntonic" with their personality. This last detail - the remorse and self hate that BPD sufferers feel when they know that they have hurt someone other than themselves makes this illness suspect as a "personality" disorder, in the long run it will probably make it's way to Axis I. If there is no desperate longing to "make it better" afterwards, it is not BPD.

So ok, it's best to stay away from someone in the throes of a BPD crisis - but you will not be so affected and you will be protected by your compassion when you really understand yourself and this very painful disorder.
If, of course, it really is BPD.

Vitriolic Virchow said...

I have dated several women with BPD. Initally, it's rather pleasant. What with being the only person who understands them, and the individual who can save them from (whatever it is that they need saving from). They tend to be intellegent. Interesting. A touch on the kinky side, or at least sexually adventurous.

The drama gets old after a while. And I can't save them. And the splitting makes things difficult.

jenne' andrews said...

Let's start with a primary problem: referring to individuals as "those people" and "borderlines". It is a diagnosis of convenience for people who are not truly dedicated to the art and practice of therapy. It is a way of relegating an individual to a label, putting her in a box with a paradigm and a destiny written on it. It would be helpful if those who decry the label would start advocating for the use of "trauma survivor"-- I daresay that covers all unfortunate enough to have had this awful, denigrating, repugnant word written into their medical charts and across their backs. Feel free to read my remarkable poetry and memoir at Loquaciously Yours, -- I am a well-known poet. xj

Jenne' R. Andrews said...

Please take a look at the piece I wrote about the broken child-- if you care about broken adult children...thanks-- j

Jenne' R. Andrews said...

Please take a look at the piece I wrote about the broken child-- if you care about broken adult children...thanks-- j

Anonymous said...

If you hate one of your patients, there might be a damn good reason why. I'm sorry, but these people drive their relatives and friends crazy too with their hyperreactive insanity. If a competent and loving therapist is being driven mad, too, it's probably because their behaviors are such as would socially alienate them just about anywhere on the planet. Don't blame the helper. Address the person who makes it impossible for the helper to help.

Anonymous said...

Hmmm... The nicest caregivers. Yes. This should be noticed. If even the most loving people have a problem with the behavior of these folks, maybe there's a problem with their behavior. Look, if there's an abused animal who is frightened, I will have compassion for that animal, but no way I'm putting my hand near if it has shown a history of hyper reactive biting. Let's not treat caregivers as if they are a problem.