Borderline Personality Disorder – a story of hope
Thanks to Eureka Street for publishing this piece on Borderline Personality Disorder. A great deal has changed about our understanding of and treatment of the condition. We now know that trauma is no longer essential to its development, and this year three separate studies demonstrated a 90% resolution rate after a 2 year period with appropriate community management. We are better at recognising early signs in adolescence, and getting help then. There is also a significant component of spirituality to its treatment, which I explore here. One way to think of a personality disorder is as a cartoonish exaggeration of a normal personality trait to the point that it affects daily life. The self-absorbed become narcissistic, unable to love anyone but themselves. The grandiose become histrionic, with garish, outlandish behaviours intended to draw others to them in a lifelong but ineffective desperation for human connection. Unlike the other personality disorders, those with borderline personality disorder (BPD) are heavily over-represented in mental health care services, with about 40 per cent of all mental health inpatients having the condition, despite only one to two per cent of the population suffering from it (BPD Foundation Consensus statement). BPD is not merely an exaggerated personality trait, but a complex mental health condition that profoundly affects an individual’s emotional regulation, relationships, and self-image. Contrary to the notion of BPD as merely a response to trauma, recent research, including studies cited by the BPD Foundation and work by scholars like Skaug (2022), points to a more nuanced understanding that includes genetic factors. The borderline are driven by a fear of abandonment. Patients with BPD often experience intense emotional pain and may exhibit behaviours that can be challenging for both themselves and the professionals seeking to help them. For instance, during my early years in psychiatry, I still vividly remember meeting with a patient in crisis who berated me so severely I was unable to tolerate talking to her any longer, and left her to be assessed by the morning doctors. The interaction lasted five minutes and happened twenty years ago. Such episodes underscore the complexity of providing care in these situations. Patients with BPD have frequent suicidality, low self-esteem and severe mood swings. My textbooks advise that this condition usually arises during adolescence. That’s a bland, academic way of describing the horrific truth — that one in 50 children from the age of twelve can one day wake up with the belief that they have to kill themselves. ‘One of those concepts, that we are loved and deserve life, is at the heart of this targeted psychotherapy — and surely at the heart of human experience itself.’ I once spoke to a father and his daughter, who presented after ten years of difficulty. Their own doctor had dissuaded them from seeing psychiatrists, believing that she would grow out of the condition, until he was finally convinced by her therapist to refer her. I asked my standard initial question: ‘Do you have a voice in your head telling you that you are a horrible person?’ Her father was shocked to hear that this voice had been present since she was eleven, and she’d never mentioned it before, out of fear. BPD has the reputation of being one of the most difficult mental disorders to treat — as well as being one of the most controversial. Most antidepressants have minimal impact on the mood features, often leading to early despondency in treatment. Early research found that 70 per cent of psychiatrists did not tell their patients that they had the condition, simply because of the stigma associated with it, and clinicians feared the potential negative impact of the diagnosis. I once worked at a service where several clinicians explained to me how important it was for patients to remain uninformed about their condition so they wouldn’t keep turning up for help. And that is one of the few saving graces of the syndrome: it pushes the sufferer to keep looking for help, in the hope that someone will be able to rescue them. There was a young woman I once met, who, after three years of repeated admissions, finally had the BPD diagnosis given to her. I was worried that she was going to take it badly, but was amazed at her relief. ‘All this time, I thought I was just a bad person. Now I know what I have.’ One breakthrough in treating BPD has been the development of Dialectical Behaviour Therapy (DBT), which I came across a few years ago. DBT has revolutionized the treatment landscape, with remission rates significantly improving, from remission rates after completed treatment of barely 30 per cent to 85 per cent. For the first time, many patients who had access to the therapy were granted a modicum of control over their inner darkness. Early critics suggested that the proponent, Dr Marsha Linehan, merely happened to be highly charismatic, but when others started replicating her methods, they continued to prove effective. One of the key components of DBT is mindfulness, something most of the public is aware of, possibly because of how simple it is to market. (Those adult colouring books you see in newsagents emerged from one of the suggested DBT exercises). Mindfulness is an acquired skill that is beneficial to the mental wellbeing of anyone, not just those with borderline personality disorder. In BPD, the mindfulness practice is directed at acknowledging and accepting one’s feelings, thoughts and sensations. It’s about learning to think in the opposite direction to the way the borderline mind wants to go. I’ve had patients liken it to learning to ride a bicycle uphill. Dialectical Behaviour Therapy is not easy. Dropout rates for initial engagements are usually higher than 60 per cent. Those who persist, succeed. It was only a few years ago that Dr Linehan admitted that she herself had borderline personality disorder. It had failed to respond to medication, or electroshock therapy, and she spent two years at an inpatient unit, largely in seclusion as its ‘worst patient’.
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