Borderline Personality Disorder -- Real disease or lazy, catch-all diagnosis?

In My Humble Opinion
101

Is this true? I asked the question upthread, but isn’t there evidence that BPD goes into “remission” or that the symptoms diminish as a person ages into their 30s and beyond? A Google search yielded this cite that says that 88% of the borderlines in the study achieved “remisison” in 10 years. Certain things make remission more or less likely, including a less traumatic childhood, being younger, comorbidity with other mental illnesses, substance abuse, etc.

This does seem to contradict the idea that BPDs are intractable, incurable, untreatable, etc. I wonder why that perception is so widespread.

102

Wow. Just wow. That shit is horrible.

Thank you all for the terrifying and eye-opening experiences, especially susan, Momofgirls, Chimera, and olivesmarch4.

I wasn’t going to say anything at first, but this thread really made me think (and feel). I’ve been mildly curious about BPD since I was diagnosed with it a decade or so ago, but I never heard first-hand accounts like this before. I didn’t think it could get quite THAT bad – I have my own share of shameful stories, for sure, but not quite to the same level of abusiveness – so it’s definitely harrowing and enlightening to hear these tales. Back then, I was so preoccupied with my own pain I never thought about how much of an asshole I was being to the people around me. Ugh…

103

Sorry it took so long to get back to this. Personal reason - no matter what you do to help them, it is NEVER ENOUGH (mind, this is in the In-Patient setting). There is ALWAYS something else they need. If they see another client getting attention, then they will do everything in their power to get that attention for themselves, up to and including faux-seizures, suicide attempts, and violence towards others. And, as others have already stated, they will NOT take responsibility for their own actions.

104

Just keep in mind it’s possible to be diagnosed with this without having a history of violence at all. As the wiki notes there are 256 different combinations of symptoms that could result in the diagnosis. So not all BPDs are necessarily abusive or dangerous. As I mentioned before, I came quite close to qualifying myself… at least four out of five, and I never harmed or threatened to harm another person. I was intensely emotional, frequently suicidal, and so depressed and anxious that I was beginning to lose my grip on reality. It must have been hell on my husband. But he’s rather amazing.

For the record, this is my favorite Straight Dope thread ever, for its informative and therapeutic value.

105

I think too that there can be a bit of the ‘catch all’ on the diagnosis in “Well, you’re a bit of an asshole, so it might be BPD” or “You sound kinda messed up and engrossed in your own pain and that might be BPD”.
Seven and a half years ago at my moment of crisis (and for months before that), I admit that I was insane. I was not balanced. My perceptions were skewed to the point that I was not capable of acting completely rational in the eyes of others - although being a person who prizes rationality, I thought I was being rational. I was wrong. I was seriously messed up and in retrospect, I’m ashamed and humiliated by how I was acting in that time period.

And there’s the thing. Pain Overwhelms. Like when I got blasted in the groin by my ex-wife, I curled into a fetal position and my entire world became about that pain. Mental, Emotional, Psychic pain does the same thing. We retreat inward and our entire world becomes about our pain. Our way of relating to other people becomes about our pain. Everything has to pass through that perception filter, which is all about our pain. This can really mess up our lives.

Other people, not having that experience or that filter, don’t know what the fuck we’re on about. They keep trying to go around the filter, or they give up in frustration and write us off. We lose more people because of the pain, and that causes still more pain, continuing the cycle.
The single most valuable thing I found in healing myself, in making productive changes to myself, was the single most difficult thing I had to learn and accept. That being complete honesty with myself. Setting aside pride and ego, setting aside ‘self’, and looking at things objectively. Putting aside anger, humiliation and most especially, BLAME. Just facing things AS THEY ARE, without pride, without blame, without ideas of guilt and punishment. Looking at them objectively and deciding, on that objective basis, what was the best course of action to correct that flaw in myself.

106

I typed a long post in this thread the other day and then accidentally hit two keys at once, and it disappeared. I was going to come back and re-do it, and then I see that Olives has summed it up pretty well, except that she is talking about my late sister, who also had bipolar disorder. When we learned of her death five years ago we were all sure it was a suicide, but it turned out to be complications of chronic alcoholism. She was 43.

Yes, it’s all the same. Accusations, threats, drugs, promiscuity, petty theft and, above all, lies lies lies. When I called my cousins to invite them to my wedding, they all said the same thing, independent of one another: “Don’t invite your sister.”

As if.

107

I couldn’t have said it better myself. Between the ages of about 17-22, I really was quite a head case. I didn’t realize it, I saw myself as a complete victim, and I lost a lot of friends who couldn’t be sucked in by the negativity. I couldn’t, as you said, see anything outside of my own filter of pain. The few people who stuck with me through that very difficult time still remark on how completely different and difficult I was at that time, and how they basically had to maintain a certain emotional distance and hope I would eventually find my way through it. My Aunt has even remarked, ‘‘The only two people to survive our family sane are you and me, and you almost didn’t.’’

The way I got through it was by accepting responsibility. This was the one thing Mom never did and I couldn’t justify living a life like that-- I didn’t want to be like her. It was Cognitive Behavioral Therapy that started this ball rolling. I realized all of these little behaviors–the conscious decision to think negative, self-defeating thoughts, refusing to go to class, not taking responsibility for my debt–all of these things were choices I made. I may have had a past full of trauma but I was the one perpetuating my own pain in the present. And once I had the clarity of mind to understand that, the hardest part was forgiving myself for being so immature. I lost a great deal as a result of that immaturity–I did well in college, but I could have done exceptionally well, and I have two terms of withdrawals on my transcript. I had 19 derogatory marks on my credit report and came damn close to bankruptcy. I was nearly fired from a cafeteria job at age 22 because I didn’t bother showing up. I turned down not one, but two opportunities to study abroad in Santiago, Chile. I have genuine regret for these missed opportunities, and I have no one to blame for myself. These were all things I did to myself!

But I have forgiven myself. I was going through immensely difficult things at that time in my life and I coped the best way I knew how. I may have been behaving like a child, but nobody ever taught me to be an adult. I have erroneously told myself through out all of this that I was some kind of uber-mature enlightened adult-minded person from about the age of 6, but the truth is, even at 17, when I was financially independent and kicking ass in all my classes and by all external measures ‘‘succeeding,’’ I was still emotionally a child. I was not a special exception. With time I’ve come to develop compassion instead of hatred for that child, wisdom instead of resentment, reflection instead of reaction.

Sigmagirl, I have a horrible, horrible question for you and you should in no way feel obligated to answer it. I have always assumed (I am the worst person* in the world*) my mother’s death would bring peace and a sense of closure to everyone in our family. Do you find yourself more at peace now that your sister is gone? Or is everything still raw and confusing? Did you ever get closure?

108

There is a percentage of those who haven’t (accidentally or intentionally) taken themselves out by the time they reach their 40s and 50s who do see a reduction in symptoms. My MIL actually had a period of several months, about a year prior to her death, where she was almost normal. Oddly, she was going through hypnosis to stop smoking at the time. It was the most peaceful the interactions with her had ever been, and my husband still remarks that he would like to think that person was who she was at the core of her being, and that the disease had simply buried that person for the majority of her life.

However, it is rare that MHPs see the tail-end of BPD; aged people tend to not want mental health assistance, so we don’t get them as much in the clinical setting, and the families have either gotten to a point of acceptance or avoidance. We usually see the full-blown cases, the ones in their 20s and 30s, and they are for the most part intractable and incurable. Also, with the current state of mental health care, we simply don’t see people for ten years. So you battle with the same shit for a year or two, or three, and throw your hands up and say screw it.

olives, I’m going to answer two of your questions. The first was directed toward me, and that’s if I allow patients to have tantrums in my office. When I had an office, I would allow certain things- yelling, cursing, punching pillows, etc- if it was therapeutic; if it was for the sake of yelling, etc., then no. But if it served a greater good- if the client was processing something by engaging in the behavior- then yes. If they needed to break something, I had things on hand that were acceptable. But I never, ever allowed them to just grab things and throw. At work now, we have several kids who I have no doubt will grow up to be BP, and they LOVE to break things. As long as they’re breaking their own stuff, I let them. They want to rip their rooms apart, destroy their radio and their gameboy and their toys? Go to it. When you calm down, you’re going to be pretty bummed out that you don’t have those things anymore. They try going after agency stuff- furniture, unit-owned radios or tvs, hallway displays, etc- they’re going to get restrained (or secluded).

Your second question wasn’t directed at me, but I’ll answer it anyway. The best thing my MIL ever did was kill herself. Her timing was, as always, HORRIBLE, and it has resulted in immense guilt for my FIL that I think he will never overcome, but it has also resulted in a sense of peace for everyone, the knowledge that there won’t be constant fights over who gets to do what, when and how, and also a much, much closer relationship between my DH and his father, which was impossible beforehand. Every single person in the family, with the obvious exception of my FIL, would say the same thing. You’re not a horrible person.

109

Thanks. Your answer made me cry a little bit. We just want peace.

Regarding the therapy thing–I’m glad to hear there are firm boundaries in place regarding acts of property destruction. I sort of figured there were, but it’s comforting to know.

110

Because the diagnosis, and initial descriptions of the disorder were established in the days when psychoanalytic and psychodynamic therapies were the only games in town. They aren’t particularly good for borderlines (unless the therapist in question is very experienced in the disorder). And in those treatments borderlines will tend to not only not get better, but maybe get a lot worse.

Basically they were taking people prone to extremely reactive emotions, a history of abuse, problems with regression and dependency, who do poorly in unstructured environments because they have poor impulse control and few coping skills - and they were putting them in unstructured therapies, encouraging them to dwell on their history of abuse, their emotions and to get dependent and regress - and surprise surprise - they get a lot worse. People who were trained in those days or by those people tend to be eye-rollers who talk about how incurable and BPDs are.

There are now BPD-targetted therapies (dialectical behavioral therapy, certain types of cognitive behavioral therapy, and a psychodynamic therapy called “mentalisation,”) that have a strong emphasis on skills-training, the here and now and and which are supposedly effective, or at least are looking not bad in clinical trials and are anyway becoming the standard of care (DBT particularly). On top of which BPD’s in general tend to get much better over time anyway. Probably more so if they avoid certain types of therapists. Most don’t fulfill the criteria for it within a few years. Some of the problems (affective dysregulation, identity disturbance) maybe hang on, but the impulsivity and acting out behaviors tend to be early-on stuff. Still 8% or so of borderlines end up committing suicide. On the other hand, that’s not exactly a surprise given that self-destructive behaviors and recurrent suicidality are two of the criteria for BPD.

The fact that it’s called a “personality disorder” doesn’t help either. In theory personality disorders are supposed to be entrenched - so there’s typically the assumption among mental health providers that if it’s called a personality disorder, it’s got to be permanent, because if it weren’t permanent, it wouldn’t be a personality disorder. It’s discouraging logic, but psychiatry is still basically a medieval “science” that has more in common with scholasticism than the hard sciences.

111

I’m afraid I’m going to have to really, really disagree with you on this. True, the term borderline came about in the 1930s, but it didn’t become the fleshed-out personality disorder it is today until somewhere around 1980- at least with the publication of the DSM III. By 1980 Ellis had been pushing REBT for 30 years, Beck had been around for 20 years, and Lazarus had been well on his way for over a decade. Never mind the behaviorists that both preceded and ran concurrently with them.

Indeed, based on your argument, I would think that the exact opposite would be true- the psychoanalysts would see greater success and therefore be on the side of “BPD is curable” simply because the lengthy procedure and supportive nature of psychotherapy with a Rogerian counselor would be exactly what a borderline would want. Therefore they would, in theory, do significantly better in that scenario than, say, in the brief solution-focused process with an uncaring curmudgeon like Ellis that they would experience with CBT.

Incidentally, both my husband and I are hardline cognitive behaviorists, have worked in a variety of facilities (with a combined nearly 30 years in the field), and are both BPD “eye-rollers.”

Only if they’re really, really misinterpreting the criteria. A personality disorder isn’t permanent any more than a personality is- think of the radical changes a “normal” person goes through between the ages of 16 and 21, or 25 and 30. The label of a personality disorder comes about because of the length of time the symptoms are present, and the pervasive nature of them. It sets them apart from someone with, say, an Axis I disorder who has been experiencing anxiety for a year when they try to go into confined areas.

112

Absolutely. I remember a woman I got to know during my clinical training who had been black-listed from EVERY substance abuse program in the state because of her non-compliant behavior. It was all everyone else’s fault. Imagine being 86’d from every program in a state. You have to be some kind of loser to accomplish that…

There is very little you can do for such people other than to stay far,far away…

113

bobkitty I don’t want to get in an argument with you and entrench your position - because there’s something at stake in that you’re seeing patients. A good book on BPD would be like Gunderson’s book? Borderline Personality Disorder - a Clinical Guide? CME on Linehan and DBT maybe?

114

stands up and applauds CBT was a major turning point for me. I had spent years in just such an unstructured talk-therapy environment and I was getting further entrenched in negative thoughts and behaviors. My therapist was hesitant to get me into CBT because she said my situation was too ‘‘complex’’ to benefit from it. But you know what? I benefited almost immediately. It pulled me out of the past and put me smack in the moment and forced me to deal with my immediate environment for the first time in years.

At least one thing I can agree on with uglybeech is that psychology is still an incomplete science in many ways. I’ll spare the rant about the prevalence of mental health treatments that don’t have a lot of evidence to back them up. It’s people like you, bobkitty, and hopefully someday me, who will be able to help pull it out of the darkness.

What do you mean by eye-rollers? Just that BPDs frustrate you?

115

I showed this thread to my husband, who’s currently a doctoral student in clinical psychology. His response, based on the coverage of Borderline from his most recent class, is that as many Borderlines age, they may no longer meet the criteria for Borderline Personality Disorder, but they are still likely to meet criteria for a differing personality disorder and they are still likely to have difficulty in relationships. Thus, while someone may no longer be ‘‘Borderline’’ per se, that individual is still not likely to be a normally functioning person.

This jibes with my Mom – she is way mellow compared to her twenties and thirties, but still clearly not normal.

116

Does this mean my friend, who now has 2 kids, is probably perpetuating the craziness, as olives’ mom did? I find that terribly sad. I guess I was hoping remission was possible because I hope she’s really as OK as she says she is.

What do BPD’s generally “mellow” into?

117

Well as much as you can study soft concepts like “not normal” or “not adjusted” it seems pretty clear that some characteristics of BPD - particularly the behavioral symptoms - tend to resolve a lot faster than more tenacious characteristics like affective and identity problems. On the other hand, again as much as you can study these things, studies seem to show that there are large subsets of BPDs who become quite well adjusted after their 20s (we’ve had at least one other person here describe themselves possibly in those terms), a subset who have lower functioning but are much better than they were when they were young (which may describe your mother), and a minority who fulfill the criteria for BPD long-term.

Whatever the residual symptomatology, that’s light years away from saying the disorder is untreatable, intractable and incurable. In fact improvement is to be expected, and prognosis doesn’t seem to distinguish it very well from the Axis I disorders as a whole, where there are often - if not typically - residual symptoms (e.g. depression and anxiety) or chronic poor adjustment (e.g. bipolar II). It suggests a better prognosis certainly than what used to be taught about BPD. Which is not to say that BPD isn’t a personality disorder or represent entrenched styles of behavior, etc. It just suggests that the distinction is a lot more murky than we’re led to believe about what it is that separates Axis I from Axis II - particularly when we’re talking prognosis and treatability.

IANAD, so I hesitate to give advice, but since the alternative here seems to be “should I cry or not at the funeral?” - here’s my 2 cents. If I had a relative with BPD my approach would be to try and get them in treatment by a specialist in personality disorders - or somewhere like a university hospital setting that has access to such specialists. If you can’t, you can’t - but my point is in this day and age a BPD diagnosis should not be cause for despair and if you can get them in treatment, then where and with whom really matters. It’s too much of a crapshoot to be seen by a generalist or someone in private practice. They need to be really carefully evaluated, not only to make sure that the thing really is BPD and not something else (cyclothymia, e.g.), but also for comorbid disorders - borderline has absurd rates of comorbidity with the affective disorders (somewhere around 70-90% IIRC), anxiety disorders, substance abuse and other personality disorders - which if left unattended are going to put the kibosh on improvement. And inexperienced generalists who do diagnose BPD not only have a tendency to convey a totally unwarranted therapeutic nihilism to their clients, or have inadequate ability or resources to manage the countertransference, or engage them in ineffective therapies, but also to ignore comorbidities once the label is given. Or, alternatively, they’ll hesitate to diagnose BPD at all and bombard them with mood stabilizers or neuroleptics, preferring to diagnose some bipolar spectrum disorder - which may or may not be there - without trying effective therapies for BPD.

118

Yes, they frustrate me- I think I said in one of my first posts in this thread that my two least favorite populations are BPD and pedophiles, for much the same reasons- but in this particular case I was referring back to uglybeech’s quote of “People who were trained in those days or by those people tend to be eye-rollers who talk about how incurable and BPDs are.” Bolding obviously mine.

Ruby, it is possible that your friend is as improved as she implies- I don’t know what relative ages we’re talking about IRT her and her children. Sometimes it takes something as simple (hah!) as settling down and having children to “snap” borderlines into a more normal pattern of behavior. There is a concern, however, that her offspring will be more likely to inherit the disorder (according to the DSM, it is five times more likely among 1st degree relatives of the BPD patient than the general population) or to have an increased risk for something similar (mood disorders, substance abuse). The only way to be really sure is to contact her- it should be fairly obvious to you if she’s changed or not. There’s no way to easily say “what” a BPD mellows into, since it’s dependent on a number of factors, but for the most part they become just slightly left of center, as opposed to waaaaaaaaay out in left field.

uglybeech, I went back through the thread and can’t seem to find where any of the MHPs said BPD was “intractable, untreatable, and incurable.” Those words have been thrown around, and I stated that in their 20s and 30s they pretty much are these things, but even the DSM will tell you:

Additionally,

Granted, I’m one version behind on DSM (I have the IV-TM), but I doubt much has changed in that short period of time. So I’m not sure why you feel like there may be a disagreement between us about whether BPDs are eventually curable or not… they are, it just takes a really, really long time, and the MHPs who work with them rarely see that change take place.

As for written resources, Gunderson has authored/coauthored several fantastic books- he’s an excellent resource. The Mason/Kreger book (Eggshells) is good for a layperson’s overview of the disorder, but I do have some issues with the suggestions given in it (that’s a lengthy discussion for another time, I think). I’ve nothing against DBT (especially since a significant portion of its underlying principles rely on CBT and behaviorism), and certainly have seen the positive studies on its effectiveness; my issue is that so few people can effectively use DBT (and I’m talking the practitioners, not the patients) because typically the ones who are drawn to it by the Zen Buddhist aspect are too… Zen to be properly CBT, and vice versa. Linehan’s book is of course considered the “bible” for practitioners, but I think that it suffers somewhat from being nearly (IIRC) 20 years old. A lot of folks prefer the workbook to the book itself, and I can certainly understand that. Kreisman’s book, also mentioned in this thread, suffers from the same issue (and I have heard complaints of it being sexist). Arthur Freeman, one of my favorite clinical authors, has a fairly new book titled “Borderline Personality Disorder: A Practitioner’s Guide to Comparative Treatments” which is (IMO) excellent. I have also heard good things about Alex Chapman’s “The Borderline Personality Disorder Survival Guide.”

Just my .02, though. :slight_smile:

119

I’m almost afraid to ask this question, as I don’t want to come across as snarky or smug. But I’m genuinely curious. How do people with BPD manage to stay in relationships long enough to get married? Are they able to hide the worst parts of the illness long enough to appear desirable as a spouse?

120

No offense to Chimera, but IME they latch onto people who have an overwhelming need to rescue or take care of others. My FIL was the oldest of four, and went directly from taking care of his mother to taking care of my MIL- he didn’t know any other way of being. My brother is a peacemaker and soft heart of the worst kind- every one of us saw that my SIL was “batshit crazy” but he wouldn’t hear of it… she had a horribly pitiful upbringing that mirrored a lot of what he’d experienced, and he was willing to overlook a lot in the belief that she would respond positively to his love. I’ve found in the residential and long-term care clinical setting that borderlines are really, really attractive to other patients because of the excitement (what’s that? want to have sex for the fifth time today? you bet! oh, you just bought me a super-expensive birthday present? no, i don’t want to know where you got the money since you don’t work) and the fact that when they like you, they REALLY REALLY REALLY like you, and that feels good to anyone.

But others’ experience may be different.