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Borderline personality disorder : Identity as the key to a life worth living

We have all grappled with one question throughout the various stages of life, and whether we may believe it or not, our minds and bodies have already answered this question in one way or another. We may not know the answer, but the way in which we live our lives is a testament to it. This question being, ‘Who am I?’ At one point or another, this question becomes increasingly important, and it lingers. All of us desire to live a life that satisfies us, and allows us to create a sense of meaning. To many of us, this question is existential, and we debate within ourselves, and with others, we read philosophy books, and we seek answers in religion, in hedonism, in spirituality, in our friendships, our children or our work.

For some individuals however, as a result of life experiences in their childhood, adolescence and continuing adulthood along with biological vulnerabilities, the core sense of self is experienced to be whatever appears to fill the gap or void in the present moment, and after its passing, comes forth a sense of emptiness which is attempted to be filled from moment to moment with whatever gratifies or brings about happiness. The self remains fleeting, incomplete and in a desperate need to be understood. I am of course talking about what is called as Borderline Personality disorder (BPD). This is a mental health condition that is far from an existential crisis, but is a pathological disturbance of identity. Our identity is always relational, the sense of ‘I’ is always in juxtaposition to an other, and thus individuals affected with this condition have a difficulty in relating with others, and it manifests in their relationships. In the general adult population, the prevalence of BPD has been reported to be from 0.7%-2.7% with the rate increasing to upwards of 20% in psychiatric settings, including in-patient facilities. Faced with an ever-present identity disturbance, the core sense of self in these individuals is experienced as fragile, based on external expectations, and the perception of others. Often times, in the lives of these individuals, it is not uncommon to observe a history of emotional/physical and/or sexual abuse in their childhood. Adverse experiences such as trauma, biological vulnerabilities such as genetic/family history, childhood experiences with parents and other attachment figures, and socio-cultural factors combine to create the clinical picture of Borderline personality disorder. In the mental health field, patients with this disorder present with an unstable sense of self, that relates with others in a manner consistent with how they are treated in the present moment. This leads to a chaotic pattern of unstable relationships, with friends and significant others, emotional dysregulation in the form of disproportionate anger-outbursts, extreme sensitivity to criticism, and a labile mood, that fluctuates from one emotion to another with mercurial swiftness.

These individuals also have an extreme sensitivity to criticism, that is immediately followed by severe reactions towards the self, in the form of rejection, or perceived feelings of abandonment. Much of the time, they often complain of a sense of emptiness, that is attempted to be filled by instant gratification through substance abuse, and reckless behaviour in the form of careless spending, sexual promiscuity, and a tendency to blame and manipulate others to avoid real or perceived abandonment. When the self feels threatened in these individuals, the intensity of emotion felt is disproportionately high, leading to various patterns of coping that are indeed self-destructive. This includes another hall-mark feature of the disorder, that includes deliberate self-harm and suicidal thoughts leading to repeated acts of harming the self through superficial cuts, and injuries. While these behaviours may vex the individual’s friends and families, it is important to understand that when the mind is faced with deep-seated sense of inadequacy and rejection, one mechanism of coping is the shifting of its focus onto other painful things, such as harming oneself, that seems to provide relief to them from those acute moments of perceived rejection. In periods of severe distress, affected individuals can even develop temporary symptoms of a loss of touch with reality, which are brief, and are fittingly called “micro-psychotic” or “quasi-psychotic” symptoms. It is important to note that even though we as the friends and families of people dealing with this disorder may be troubled by these observations, we must strive to remember two things. One, that understanding and empathic listening are essential to helping those around us who may be suffering with this disorder. We must be there for them, for the pain that is felt by these individuals, although intense and severe, is real. We have all dealt with moments of rejection and despondency in our lives, and the best we can do is be there for ourselves, and to seek support with trusted friends and family members. The second, is that professional help and treatment for this disorder is available with the help of dedicated mental health services.

Psychotherapy is considered the treatment of choice for Borderline personality disorder, and indeed offers the prospects of hope and recovery for individuals suffering with this disorder. In fact, BPD as a disorder may be less stable than traditionally believed. Many naturalistic follow-up studies have showed considerable rates of recovery, and relatively low rates of relapse in people treated for the disorder. There are a number of different therapeutic approaches that can be used to help patients with this disorder. Popular among them is Dialectical behaviour therapy, developed by Dr Marsha Linehan, who herself was diagnosed with the disorder and researched what helps and doesn’t help individuals with the disorder. This therapy requires a multidisciplinary team of professionals that helps equip individuals to employ a plethora of specific skills that individuals can employ to cope with, and overcome symptoms of the disorder. Distress tolerance skills focus on managing acute moments of intense emotional experiences that can cause suffering, Mindfulness skills focus on the philosophy of Zen Buddhism, with a focused awareness on the present moment, teaching patients that each emotion is fleeting and temporary. This helps individuals to ground themselves.

Interpersonal effectiveness skills enable patients to overcome self-destructive patterns of perceiving and interacting in their social relationships. Lastly, emotional regulation skills teach patients to deal with finding meaning and tolerating deeply unpleasant emotional states. As associated mental health conditions such as substance abuse and depression can be commonly associated with the disorder, the use of medication for these conditions along with psychotherapy can holistically enable professionals to help affected individuals overcome their difficulties and find meaning in their lives and their identity. Apart from therapy, acute management of crisis situations, that pose a high risk of self-harm or suicide can be readily managed with the help of a dedicated crisis intervention team, and suicide prevention protocols.
If you or a loved one, find yourself to be suffering from the symptoms listed above, just know that help is right around the corner, and that BPD is a treatable condition. We, as mental health professionals can help you on the road to recovery, to discover yourselves, and find meaning. This road begins with you.

Summary: Borderline personality disorder (BPD) is a common mental health condition, that is characterised by fundamental difficulties in the way in which individuals perceive their sense of self, and their relation to others. Although it does not have a single aetiological cause, it is often associated with traumatic experiences in childhood, such as physical/sexual abuse, and biological vulnerabilities. Its symptoms include, a fragile, fluctuating sense of self, characterised by emotional dysregulation in the form of fluctuating intense emotional states, a perceived fear of abandonment, an unstable pattern of relationships, impulsivity, chronic feelings of emptiness, self-harm, suicidality and in certain cases, brief lasting psychotic states known as ‘micro-psychotic’ episodes. There is an association between BPD and other mental health conditions such as Major depression and substance use disorders. Psychotherapy is the treatment of choice in patients with the disorder, and BPD with co-morbidities may require the use of medication in addition to psychotherapy. Dedicated crisis intervention services can help patients deal acutely distressful situations, followed by psychotherapy to address the more enduring symptoms of the disorder. It is a treatable condition that requires consistency, social support, and specialised management that can be readily provided by mental health professionals.