Borderline Personality Disorders

The popular description of the borderline personality disorder (BPD) focuses on individuals who cannot tolerate routine, are incapable of insight, who are inclined to lead chaotic lives and who have little to no empathy with others. Friends and family suffer with them as they (the people around them) are the targets of rage. They exhibit unpredictable mood shifts and behaviour and the BPD blame people close to them for deliberately causing them pain.

Key characteristics of BPD are:
Affect dysregulation: which refers to an unusual intensity of emotional responses and a slow return to baseline. The affect is highly variable and they show intense response to environmental triggers. They react to non-verbal cues and are quick to read threat. Moods may change from hour to hour. There is a greater possibility of experiencing anger, anxiety and shame. Their moods do not include all emotions equally. Their experience of fear and anxiety reflects a double message, which involves fear of abandonment and rejection on the one hand and fear of merging and getting too close to people on the other hand. They experience an intense need for love vs an intense fear of abandonment. These fears may flow from a history of poor attachment and memories of abandonment. The role of brain functioning is very important, as the memories reactivate the amygdale, which is involved with emotional memory. Feelings of losing control, causes regression to memories of rejection. They experience themselves as defective, bad and worthless. This feeling is not built on conscious memories but they are felt and these are created thoughts and feelings of shame. Uncontrolled aggression is the most common defense mechanism to hide behind painful experiences. So, should a BPD become ashamed or tensed, he will project aggression and show rage. Depression is experienced but short lived. They don’t experience a continuous low mood. Their coping skills are characterized by acting out behaviour (destructiveness, sexual perverse activity, self destructiveness, cutting themselves, suicide attempts); regression to prior childhood patterns (being late or forcing someone to phone them to wake up in the morning, despite being able to set an alarm). They often suddenly withdraw and seem inhibited. Passive-aggression such as manipulation and sarcasm occur. They often dissociate from themselves – they may deny that they ever had a feeling of love for someone, whilst they are cross with the person. They tend to project their own feelings onto others – why do you hate me so much?
Impulsivity or disinhibition: sudden outbursts of rage, uncalled for; self destructive behaviour such as substance abuse, promiscuity, addictions (anorexia, bulimia, gambling, shoplifting and excessive spending, self-mutilation) may occur. Self-mutilation or inflicting pain is an attempt to relieve mental pain by inflicting emotional anesthesia. The sight of their own bleeding, bruises or burns allow for an almost orgasmic release. The endogenous endorphins are released into the bloodstream and the brain.
Identity diffusion and interpersonal problems: BPD individuals feel dissociated, empty, bored, lonely which suggest identity disturbance and which impacts all kinds of relationships. Intimate relationships begin with intense emotion, an over connectivity and later they break up the same way with rage and impulsivity. Extreme bonding may also occur – they may invite themselves to a quick cup of coffee, after which one can’t get rid of them or connect with an acquaintance as if they were life long friends.
Cognitive functioning: their thoughts may become distorted. They may experience paranoia. On a different level they may also justify unacceptable behaviour such as stealing.

BORDERLINE DISORDER IN CHILDREN

Borderline pathology in childhood is associated with the same neuropsychological abnormalities as seen in adult BPD, showing defects in executive functioning, associated with:
· Impulsivity: They easily become overwhelmed by inner and external pressure and with minimal provocation or anxiety, will throw fits of rage, loose control and bite others, be destructive and show paranoia. Their life style seems erratic – they are in either hypo- or hypertonic states.
· Anxiety: they show free floating and chronic anxiety; they fear separation; they fear their own disorganization and aggression and need a caring adult to help them regulate their feelings.
· Depression: a negative self image has a negative affect.
· Defense mechanisms include fantasy, projection, denial, ritualistic behaviour to ward off negative feelings such as anxiety.
· Disturbed sense of self includes an unstable self-concept including feelings of emptiness and nothingness.
· Interpersonal relationships: they are clinging and focus on adults to gratify basic needs such as love, since they have not introjected love during development, mainly due to an attachment problem. They seem socially isolated and don’t make friends easily.
· Their cognitive functioning is characterized by short attention span, poor spatial orientation and impaired memory. They are capable of logic, although their reality testing is distorted by their expectancy or anticipation of emotional pain or abandonment.

ETIOLOGY – HOW DOES IT ALL START?

This disorder is experience dependent and interactions may play a more important role than dramatic life events. Children can be resilient even in the face of such events. Genetics do play a role, so does neurologically based vulnerability. An individual may be born with impaired brain circuitry for modulation of moods and impulsivity. So, psychologically adverse events could amplify personality traits. The quality of attachment is regarded the most important factor. A child’s brain links up to the mother’s brain to learn self-regulatory capacities. Joy, laughs or anger, distancing, early neglect are all experiences that the child internalizes and engraves in his brain (anterior cingulate in the prefrontal cortex that organizes social, emotional and cognitive functions). Absence, lack of attachment or sexual/physical abuse, result in non-attunement between the child and mother or caretaker. No feedback on the baby’s smiles cause an inner emptiness and leaves the child with no mirror image from which he should experience a self or introject feelings.

The role of the brain: the amygdale involves emotional memory: the insula and anterior cingulate are associated with self image. The insula is associated with love or rejection and connects with self awareness. Should a child experience neglect, abuse, abandonment, or sees disgust or despair in the eyes of the caretaker or parent, the insula associates the experience with shame, pain, discomfort and rejection. Should these situations repeat, a post traumatic flashback is engraved in the neuronal loop and the uncomfortable emotion is learnt and becomes part of the daily experiences as well as the personality.

TREATMENT PLAN

As BPD accompany symptoms of bipolar disorder, depression, post traumatic stress disorder, ADHD, psychosis, dissociative disorder, eating disorders and substance abuse, it is important to differentiate in order to follow the correct treatment plan. The wrong medication, for instance prescribing anti depressants not keeping in mind that their depression is short lived, may make them worse.

The treatment plan should be on a multi disciplinary level including psychotherapy, in certain cases medication may play a role, as well as neurotherapy , during which the brainwaves are monitored.

Neurotherapy is non-invasive in other words, no impulses go into the brain.

How does the training work? Through operant conditioning: this is a process through which the brain gets visual and auditive feedback when it produces productive and effective brain frequencies. When the brain produces ineffective frequencies, in other words, if the brain is either over or under aroused, problems are experienced on a behavioural, cognitive and emotional level as well as interpersonal levels. The level of arousal of the brain is normalized or stabilized in order to ward off tension and other negative feelings. Specific focus is placed on the cingulate and amygdale as mentioned before.

Annemie Peché
For more information please phone: 0823356133