BORDERLINE PERSONALITY DISORDER           INSTABILITY IS THE RULE!!!

Natasha* had slit her right wrist very deep when she was brought to the hospital. She was not guilty and said hurting self gave her pleasure. She actually wanted to die and said one day she will succeed in putting an end to her wretched life. After an ice breaking session she revealed that she had no friends and those whom she loved always went away. Her recent break up had shattered her completely and she wanted to die. She told how she had been molested and manhandled by her cousin in childhood and how her school van driver had tried to rape her when she was ten. Her parents didn't love her enough and her grandparents always wanted a male child. Ever since then, started this unending quest to be loved and accepted and somehow it was never satisfied. She was diagnosed with Borderline personality disorder and treatment was started. 

What is borderline personality disorder?Borderline personality disorder is a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with borderline personality disorder may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days. The pattern of behaviour often lasts a lifetime. However the intensity of emotional outbursts may reduce with age. There is often a history of childhood abuse - physical, emotional or sexual. Unhappy memories of an emotionally turbulent younger age along with neglect or overinvolved parental attachment is often ellicited from the patient. 

Signs and Symptoms

People with borderline personality disorder may experience mood swings and display uncertainty about how they see themselves and their role in the world. It is difficult for them to have stable views and interests and often change their vocation.

 People with borderline personality disorder also tend to view things in extremes, such as all good or all bad. Their opinions of other people can also change quickly. An individual who is seen as a friend one day may be considered an enemy or traitor the next. These shifting feelings can lead to intense and unstable relationships. Often they are left lonely. Other signs or symptoms may include:

1.Efforts to avoid real or imagined abandonment, such as rapidly initiating intimate (physical or emotional) relationships or cutting off communication with someone in anticipation of being abandoned

2.A pattern of intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)

3.Distorted and unstable self-image or sense of self. Low confidence at times. 4.Impulsive and often dangerous behaviors, unsafe sex, substance abuse, reckless driving, and binge eating. 

5.Self-harming behavior, such as cutting, wrist slashing. 

6.Recurring thoughts of suicidal behaviors or threats.

 7.Intense and highly changeable moods, with each episode lasting from a few hours to a few days

8.Chronic feelings of emptiness. 9.Inappropriate, intense anger or problems controlling anger. Rage episodes where they make break articles and inflict wounds on self and ones close to them. 

10.Difficulty trusting, or total child like trust which is sometimes accompanied by irrational fear of other people’s intentions. 

The only thing stable about this personality is the instability! They are often mercurial and fickle minded. They can't be satisfied. They view everything in black and white. Nothing in between. But they are also often very creative and can go to any extent to charm their object of interest. 

Treatment consists of first establishing rapport with the patient and getting details of her childhood and developmental history. Parenting and childhood trauma needs to be addressed. The current crisis needs to be understood. Then starts the training of mindfulness and understanding and changing the current distressing emotional state. Dialectical behaviour therapy is tailor made to the needs of the patient. 

Some therapists work on mentalisation based treatment and some others on psychodynamic oriented therapy. 

However an eclectic approach combining principles of various concepts often are more useful to the patient. 

Simple things like how to keep busy, how to improve sustenance and persistence with goals need to be emphasised. Developing and maintaining relationships and controlling emotional outburst needs to be discussed. Childhood trauma needs to be addressed. 

The doctor also needs to be sensitive about her own emotions. Sometimes patients may get over attached or may swing between feelings of extreme hate and total love. At times it may seem that the patient is deliberately trying to provoke the doctor or may be extremely attention seeking. This needs to be handled professionally. The idea is to make the patient independent and not dependent. 

It's challenging to treat borderline personality disorder. The patient is on an emotional rollercoaster and the doctor needs to teach the patient to tame her emotions. The process is difficult but not impossible. Patience is the key.