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Quinta-feira, 13 de Julho de 2006

mais pesquisas sobre borderline personality disorder

Borderline Personality Disorder

           Borderline personality disorder (BPD) is a serious and complex mental illness that affects 2 – 3% of the population. Once thought to be on the “border” of schizophrenia, BPD is now believed to be more closely related to mood disorders such as depression, or possibly to impulse control disorders like Attention-Deficit/Hyperactivity Disorder. People with BPD have difficulty regulating their emotions and controlling their impulses. They often act out their emotions or impulses, either through intense inappropriate displays of anger, or through self-injurious or suicidal behavior. Although self-injury often occurs without suicidal intent, a significant number of people with BPD die by suicide.

            Depression and anxiety are common in people with BPD, and many also struggle with addiction problems. Individuals with BPD often need extensive mental health services, and they account for 20% of psychiatric hospitalizations. Despite the seriousness of the disorder, recent research indicates that treatment can lead to considerable improvement over time, and there is hope for recovery.

What are the symptoms of BPD?

            Individuals with BPD display a pattern of dramatic mood swings, irritability, and intense anger. Mood swings typically occur in response to stressful life situations, and in particular to difficulties in interpersonal relationships or interpersonal conflict. Individuals with BPD are intensely sensitive to rejection or perceived abandonment, and when they feel they are being abandoned they often respond with explosive anger or with self-injurious or suicidal behavior. Because these behaviors take a toll on close interpersonal relationships, individuals with BPD often provoke the very rejection and abandonment they fear.

            Other BPD symptoms include feelings of emptiness or boredom; identity confusion; and impulsive behavior such as over-spending, risky sex, substance abuse, reckless driving, or binge eating. BPD individuals sometimes display brief stress-related periods of paranoid or irrational thinking. They also tend to think in “black and white” terms, alternating between extremes of idealization (everything is wonderful) and devaluation (everything is terrible).

What causes BPD?

            At one point, BPD was believed to be caused by faulty parenting, and many families felt unfairly blamed. Our current understanding is that BPD has a strong biological component, and that it results from a combination of genetic and environmental factors. Recent research suggests that individuals suffering from BPD have imbalances in the neurotransmitters that regulate emotion and impulse control. Serotonin is one neurotransmitter believed to play a significant role in BPD. When individuals suffer from this type of an imbalance, life stresses can easily overwhelm their coping abilities.

            Although BPD may develop purely as a result of a biological “vulnerability,” research indicates that many individuals with BPD do have a history of traumatic early childhood experiences. About 50 – 70% of individuals with BPD report a history of childhood sexual abuse. Many also report histories of verbal or physical abuse. Often there is a pattern of inconsistent parenting and poorly met needs that may stem from parental addictions or mental illness. A history of early loss or traumatic abandonment is also common, possibly due to death of a parent or parental separation.

What is the effect of BPD on family members?

            Family members often feel mystified and exhausted by their relative’s illness. The intense mood swings and anger outbursts can be frightening and disruptive. Impulsive acting out in areas such as spending, substance abuse, or sex can be a major source of marital conflict. Relatives are often overwhelmed with worry regarding their loved one’s safety following repeated suicide attempts or acts of self-mutilation. At times, partners and family members feel manipulated by these suicidal or self-destructive behaviors, and are torn between reaching out to their loved one, and setting personal limits and boundaries. It is not unusual for relatives and spouses of BPD individuals to feel depressed themselves, and to struggle with feelings of guilt, shame and helplessness.

What help is available?

            A number of effective treatment options are emerging to help BPD individuals and their families. Some of these options include:

Medication Medications can be helpful in reducing symptoms of depression, anxiety, irritability and paranoid thoughts. Medications may also help improve emotional and impulse control, thereby reducing stress in marital or family relationships and making it easier to develop new interpersonal or stress management skills in psychotherapy.

Individual Psychotherapy Often, psychotherapy is required to achieve lasting personality change. Short-term or brief-therapy may be helpful in stabilizing immediate crises. Psychodynamic Therapy helps make connections between early traumatic experiences and ways that learned behavior patterns are repeated in current relationships. Cognitive-Behavioral Therapy, and in particular a version of it known as Dialectical Behavior Therapy, has proven helpful in altering negative patterns of thinking, and in learning new behaviors and coping strategies.

Group Therapy Group Therapy is often helpful in learning and practicing new interpersonal skills and increasing awareness of problematic interpersonal traits and behaviors.

Brief Hospitalization Hospitalization may be necessary to ensure safety during suicidal crises or episodes of self-injury. Some hospitals offer brief intensive treatment programs for BPD.

Marital or Family Therapy Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one’s illness.

            Marriage and Family Therapists (MFTs) can be excellent treatment providers for individuals and families who are struggling with the effects of BPD. MFTs are trained to recognize and treat BPD using many of the treatments described above. Because of their knowledge and expertise in family relationships, MFTs can help reduce the impact of BPD symptoms on family relationships, and improve overall marital and family functioning.

Consumer Resources


New Hope for People with Borderline Personality Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary Solutions, by Neil R. Bockian, Nora Elizabeth Villagran, and Valerie Porr. Prima Publishing, 2002.

Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder, by Paul T. Mason and Randi Kreger. New Harbinger, 1998.

The Stop Walking on Eggshells Workbook: Practical Strategies for Living with Someone Who Has Borderline Personality Disorder, by Randi Kreger and James Paul Shirley. New Harbinger, 2002.

Lost in the Mirror: An Inside Look at Borderline Personality Disorder, by Richard A. Moskovitz. Taylor Publishing, 2001.

I Hate You—Don’t Leave Me: Understanding the Borderline Personality, by Jerold J. Kreisman and Hal Straus. HarperCollins, 1989.


Personality Disorders Awareness Network (PDAN)

A non-profit organization offering Internet resources and support for family members.

National Educational Alliance for Borderline Personality Disorder (NEA-BPD)

A non-profit organization focused on families that aims to provide education regarding BPD. Phone: 914-835-9011

Internet Resources

Borderline Personality Today

An excellent website providing a wide range of information on BPD.

The text for this brochure was authored by Malcolm M. MacFarlane, M.A.

©2003 by the AAMFT.





publicado por xgirlx às 23:00
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Quarta-feira, 12 de Julho de 2006

Borderline Personality Disorder

Borderline Personality Disorder

Borderline Personality Disorder (BPD) is one of the most controversial diagnoses in psychology today. Since it was first introduced in the DSM, psychologists and psychiatrists have been trying to give the somewhat amorphous concepts behind BPD a concrete form. Kernberg's explication of what he calls Borderline Personality Organization is the most general, while Gunderson, though a psychoanalyst, is considered by many to have taken the most scientific approach to defining BPD. The Diagnostic Interview for Borderlines and the DIB-Revised were developed from research done by Gunderson, Kolb, and Zanarini. Finally, there is the "official" DSM-IV definition.

Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder: in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD. Others believe that the term "borderline personality" has been so misunderstood and misused that trying to refine it is pointless and suggest instead simply scrapping the term.

What causes Borderline Personality Disorder?

It would be remiss to discuss BPD without including a comment about Linehan's work. In contrast to the symptom list approaches detailed below, Linehan has developed a comprehensive sociobiological theory which appears to be borne out by the successes found in controlled studies of her Dialectical Behavioral Therapy.

Linehan theorizes that borderlines are born with an innate biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. They peak "higher" emotionally on less provocation and take longer coming down. In addition, they were raised in environments in which their beliefs about themselves and their environment were continually devalued and invalidated. These factors combine to create adults who are uncertain of the truth of their own feelings and who are confronted by three basic dialectics they have failed to master (and thus rush frantically from pole to pole of):

  • vulnerability vs invalidation
  • active passivity (tendency to be passive when confronted with a problem and actively seek a rescuer) vs apparent competence (appearing to be capable when in reality internally things are falling apart)
  • unremitting crises vs inhibited grief.

DBT tries to teach clients to balance these by giving them training in skills of mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation.

Kernberg's Borderline Personality Organization

Diagnoses of BPO are based on three categories of criteria. The first, and most important, category, comprises two signs:

  • the absence of psychosis (i.e., the ability to perceive reality accurately)
  • impaired ego integration - a diffuse and internally contradictory concept of self. Kernberg is quoted as saying, "Borderlines can describe themselves for five hours without your getting a realistic picture of what they're like."

The second category is termed "nonspecific signs" and includes such things as low anxiety tolerance, poor impulse control, and an undeveloped or poor ability to enjoy work or hobbies in a meaningful way.

Kernberg believes that borderlines are distinguished from neurotics by the presence of "primitive defenses." Chief among these is splitting, in which a person or thing is seen as all good or all bad. Note that something which is all good one day can be all bad the next, which is related to another symptom: borderlines have problems with object constancy in people -- they read each action of people in their lives as if there were no prior context; they don't have a sense of continuity and consistency about people and things in their lives. They have a hard time experiencing an absent loved one as a loving presence in their minds. They also have difficulty seeing all of the actions taken by a person over a period of time as part of an integrated whole, and tend instead to analyze individual actions in an attempt to divine their individual meanings. People are defined by how they lasted interacted with the borderline.

Other primitive defenses cited include magical thinking (beliefs that thoughts can cause events), omnipotence, projection of unpleasant characteristics in the self onto others and projective identification, a process where the borderline tries to elicit in others the feelings s/he is having. Kernberg also includes as signs of BPO chaotic, extreme relationships with others; an inability to retain the soothing memory of a loved one; transient psychotic episodes; denial; and emotional amnesia. About the last, Linehan says, "Borderline individuals are so completely in each mood, they have great difficulty conceptualizing, remembering what it's like to be in another mood."

Gunderson's conception of BPD

Gunderson, a psychoanalyst, is respected by researchers in many diverse areas of psychology and psychiatry. His focus tends to be on the differential diagnosis of Borderline Personality Disorder, and Cauwels gives Gunderson's criteria in order of their importance:

  • Intense unstable relationships in which the borderline always ends up getting hurt. Gunderson admits that this symptom is somewhat general, but considers it so central to BPD that he says he would hesitate to diagnose a patient as BPD without its presence.
  • Repetitive self-destructive behavior, often designed to prompt rescue.
  • Chronic fear of abandonment and panic when forced to be alone.
  • Distorted thoughts/perceptions, particularly in terms of relationships and interactions with others.
  • Hypersensitivity, meaning an unusual sensitivity to nonverbal communication. Gunderson notes that this can be confused with distortion if practitioners are not careful (somewhat similar to Herman's statement that, while survivors of intense long-term trauma may have unrealistic notions of the power realities of the situation they were in, their notions are likely to be closer to reality than the therapist might think).
  • Impulsive behaviors that often embarrass the borderline later.
  • Poor social adaptation: in a way, borderlines tend not to know or understand the rules regarding performance in job and academic settings.

The Diagnostic Interview for Borderlines, Revised

Gunderson and his colleague, Jonathan Kolb, tried to make the diagnosis of BPD by constructing a clinical interview to assess borderline characteristics in patients. The DIB was revised in 1989 to sharpen its ability to differentiate between BPD and other personality disorders. It considers symptoms that fall under four main headings:

  1. Affect
    • chronic/major depression
    • helplessness
    • hopelessness
    • worthlessness
    • guilt
    • anger (including frequent expressions of anger)
    • anxiety
    • loneliness
    • boredom
    • emptiness
  2. Cognition
    • odd thinking
    • unusual perceptions
    • nondelusional paranoia
    • quasipsychosis
  3. Impulse action patterns
    • substance abuse/dependence
    • sexual deviance
    • manipulative suicide gestures
    • other impulsive behaviors
  4. Interpersonal relationships
    • intolerance of aloneness
    • abandonment, engulfment, annihilation fears
    • counterdependency
    • stormy relationships
    • manipulativeness
    • dependency
    • devaluation
    • masochism/sadism
    • demandingness
    • entitlement

The DIB-R is the most influential and best-known "test" for diagnosing BPD. Use of it has led researchers to identify four behavior patterns they consider peculiar to BPD: abandonment, engulfment, annihilation fears; demandingness and entitlement; treatment regressions; and ability to arouse inappropriately close or hostile treatment relationships.

DSM-IV criteria

The DSM-IV gives these nine criteria; a diagnosis requires that the subject present with at least five of these. In I Hate You -- Don't Leave Me! Jerold Kriesman and Hal Straus refer to BPD as "emotional hemophilia; [a borderline] lacks the clotting mechanism needed to moderate his spurts of feeling. Stimulate a passion, and the borderline emotionally bleeds to death."

Traits involving emotions:

Quite frequently people with BPD have a very hard time controlling their emotions. They may feel ruled by them. One researcher (Marsha Linehan) said, "People with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement."

1. Shifts in mood lasting only a few hours.

2. Anger that is inappropriate, intense or uncontrollable.

Traits involving behavior:

3. Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more than once

4. Two potentially self-damaging impulsive behaviors. These could include alcohol and other drug abuse, compulsive spending, gambling, eating disorders, shoplifting, reckless driving, compulsive sexual behavior.

Traits involving identity

5. Marked, persistent identity disturbance shown by uncertainty in at least two areas. These areas can include self-image, sexual orientation, career choice or other long-term goals, friendships, values. People with BPD may not feel like they know who they are, or what they think, or what their opinions are, or what religion they should be. Instead, they may try to be what they think other people want them to be. Someone with BPD said, "I have a hard time figuring out my personality. I tend to be whomever I'm with."

6. Chronic feelings of emptiness or boredom. Someone with BPD said, "I remember describing the feeling of having a deep hole in my stomach. An emptiness that I didn't know how to fill. My therapist told me that was from almost a "lack of a life". The more things you get into your life, the more relationships you get involved in, all of that fills that hole. As a borderline, I had no life. There were times when I couldn't stay in the same room with other people. It almost felt like what I think a panic attack would feel like."

Traits involving relationships

7. Unstable, chaotic intense relationships characterized by splitting (see below).

8. Frantic efforts to avoid real or imagined abandonment

  • Splitting: the self and others are viewed as "all good" or "all bad." Someone with BPD said, "One day I would think my doctor was the best and I loved her, but if she challenged me in any way I hated her. There was no middle ground as in like. In my world, people were either the best or the worst. I couldn't understand the concept of middle ground."
  • Alternating clinging and distancing behaviors (I Hate You, Don't Leave Me). Sometimes you want to be close to someone. But when you get close it feels TOO close and you feel like you have to get some space. This happens often.
  • Great difficulty trusting people and themselves. Early trust may have been shattered by people who were close to you.
  • Sensitivity to criticism or rejection.
  • Feeling of "needing" someone else to survive
  • Heavy need for affection and reassurance
  • Some people with BPD may have an unusually high degree of interpersonal sensitivity, insight and empathy

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

This means feeling "out of it," or not being able to remember what you said or did. This mostly happens in times of severe stress.

Miscellaneous attributes of people with BPD:

  • People with BPD are often bright, witty, funny, life of the party.
  • They may have problems with object constancy. When a person leaves (even temporarily), they may have a problem recreating or remembering feelings of love that were present between themselves and the other. Often, BPD patients want to keep something belonging to the loved one around during separations.
  • They frequently have difficulty tolerating aloneness, even for short periods of time.
  • Their lives may be a chaotic landscape of job losses, interrupted educational pursuits, broken engagements, hospitalizations.
  • Many have a background of childhood physical, sexual, or emotional abuse or physical/emotional neglect.

go to list of BPD treatment programs

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