Tuesday, December 14, 2010

When Borderline Personality Disorder Goes Untreated

Stuart K. Hayashi

I'm going to discuss what I know about Borderline Personality Disorder (BPD), or at least my interpretation of what I have read on the matter. For the sake of readability, I shall refer to people who exhibit BPD symptoms as "Borderlines"; I do not intend for the term to be derogatory. It's too cumbersome for me to repeatedly employ the phrase "people with BPD."

I make a distinction between those who have taken the initiative to seek treatment for this condition versus those who show symptoms but have not chosen to seek professional help in a number of years ("untreated Borderlines"). When this blog post makes a generalization about "Borderlines," it is primarily referring to those who have not recovered from their condition and are not currently in treatment. I have communicated with individuals who have informed me that they have been diagnosed with this condition and are receiving the medical attention they need. Bear in mind that they might disagree with much of what appears in this post and on this blog. I know that not everyone with this condition is the same; there is variation.

As I am not a psychologist, one may question the veracity of the information contained in this post. For that reason, I shall provide links to online documents written by those who are more knowledgeable about this subject than I am.

I understand that if someone claims to be able to explain to me what is wrong with me psychologically, I can interpret that explanation as patronizing. Such attempts by someone else to explain me usually are. What is most important, though, is not whether any such explanation comes across as condescending, but whether or not it is actually supported by facts.

First off, if someone is able to go to work or school every day and appear perfectly normal to most acquaintances, that it not proof of any absence of BPD. That may only indicate that someone is a high-functioning Borderline.

Secondly, I want to address 4degreez.com's online "Personality Disorder Test." As the test itself admits, the test cannot be used to determine whether someone has or does not have any particular disorder. That is, you can have BPD and still score "low" for BPD on that test. This is particularly because, as I shall explain later, the test questions measure the extent to which you fit the profile of an outwardly aggressive "raging" Borderline, as opposed to the inwardly-focused "Quiet Borderline." Someone who is a severe "Quiet Borderline" will score "low" in the test's BPD category.

The Nine Criteria
To be diagnosed with BPD, one must possess at least five of the nine following traits over a considerable period of time.

1. Unstable sense of identity -- According to PsychCentral, Borderlines can have "sudden and dramatic shifts in self-image, characterized by shifting goals, values and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values and types of friends." Such changes can often seem arbitrary and perplexing to those who know the untreated Borderline. With respect to gender identity, the Borderline may feel uncomfortable with her own gender, and there may be times when the Borderlines wishes that she were a member of the opposite sex. While I do not consider bisexuality, as such, to be unhealthy, it is noticeable that bisexuality commonly occurs in Borderlines (note that recovered Borderlines, who have managed to gain control over their lives, often remain bisexual; to learn more about the fluctuations in sexual orientation, read this). On a related note, it is not unusual for some Borderlines to feel alienated from their own bodies and to see themselves as "ugly." That condition is known as Body Dysmorphic Disorder.

2. "A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation" (quoted section from here) -- Here, the Borderline has black-and-white feelings, where you are either everything to her or nothing to her. In relationships, the Borderline may initially only feel comfortable in the "honeymoon" stage of the relationship. Beyond that point, the relationship can feel like a burden and become a source of an inordinate quantity of anxiety. It is Borderlines who have stuck with treatment that are the most able to sustain loving long-term relationships. If someone clings to the same clique of people for six years, the relationship with the group's members can still be considered unstable if it is marred by serious personal betrayals.

3. Suicidal imagery, suicidal gestures or physically self-harming behavior, such as in the form of cutting one's wrists with a knife -- To quality for this criterion, one need not make serious attempts to commit suicide, or even be at a strong risk for committing suicide (however, 1 in 10 persons diagnosed with BPD do commit suicide; compared to the general population, that is a high suicide rate).  One who qualifies in this category, of having "suicidal ideation," at least has frequent and disturbing contemplations about death, or fixates on imagery relating to death.  If one consistently tries to make oneself look like a dead body experiencing pallor mortis, ready for burial, that might qualify. 

4. Emotional instability

5. Feelings of emptiness -- Feeling hopeless, as if life has no meaning.

6. Inappropriate anger -- This is where people often get the idea that Borderlines yell and scream a lot. A Borderline does not have to outwardly exhibit anger to fulfill this criterion. The anger can be repressed and unexpressed. A Borderline who holds her anger in, or tries to deny that she has strong anger, can be a Quiet Borderline, as described here.

7. Transitive paranoid ideation or dissociative symptoms -- "Dissocation" refers to mysterious forgetfulness and/or feeling alienated and remote from one's own feelings.  If someone "zones out" a lot -- as if sleeping with one's eyes open -- that might qualify as dissociation. Someone might be exhibiting transitive paranoid thoughts if she complains "All men only like me for my hair color and want to have sex with me" (and says this in a very serious, offended manner) or if she keeps switching back and forth between praising an acquaintance as friendly and accusing him of being criminally dangerous.

8. Potentially self-damaging impulsive behavior in two areas other than suicide threats and deliberate self-harm (like cutting) -- These potentially self-damaging impulsive behaviors typically come in the form of substance abuse, gambling, reckless driving, or eating disorders. However, there are other forms. One possible example would be playing an online video game for many hours on end, as if being addicted to it.

9. Abandonment issues -- If someone constantly claims that everyone abandons her, or if she is very clingy and emotionally needy toward someone while she is infatuated with him, it may be a sign of BPD abandonment issues.

Other Concerns
There are other matters that must be addressed. Remember that to be diagnosed with BPD, you need to fit 5 out of the 9 criteria listed above. Imagine that in the years 2003 and 2004, I fit all nine criteria. That means that, even if I was not diagnosed with BPD, I probably should have been. Also imagine that I did have psychotherapy, but I was not, to my knowledge, being specifically treated for BPD. Maybe I discontinued this treatment and thought about going back in 2006, but eventually decided against it. Now suppose that by 2010, I can only fit three of the criteria -- the unstable self-image, the unstable relationships, and the paranoid thoughts -- but that I exhibit such symptoms in very extreme and disturbing ways. Technically, because I fit fewer than five criteria now, that means that I would not be able to be diagnosed with BPD anymore. That would not mean, however, that I should be considered "recovered." If someone manifests any of these criteria to such an extent that it interferes with her long-term life goals and happiness -- or if it prevents her from even holding onto any long-term life goals -- then she should keep in mind that she still may possess harmful BPD traits and that she may benefit from resuming treatment with a mental health professional.

Also note that BPD is often mistaken for Bipolar Disorder. If someone compares your moodiness to a business cycle in that it will go up and down like the stock market, that is his not-so-subtle way of hinting to you that he thinks you might be bipolar. Naturally, the two conditions are not mutually exclusive; almost 20 percent of BPD sufferers are also diagnosed with Bipolar Disorder.

If someone acts confident most of the time, that is not evidence that she does not have BPD. Psychologist Paul Mason and author Randi Kreger provide this apt description of high-functioning Borderlines.
They may hide their low self-esteem behind a brash, confident pose that hides their inner turmoil. They usually function quite well at work and only display aggressive behavior toward those close to them (high functioning). But the black hole in the gut and their intense self-loathing are still there. It’s just buried deeper
Repeatedly proclaiming oneself to be some great real-estate investor, for instance, may be attempted as "proof" that one is responsible and stable, but that is meaningless and empty if one continues to hate oneself.

Finally, infidelity is not unheard-of among untreated Borderlines. When looking at the high percentages of non-Borderlines who have been unfaithful, I don't have scientific evidence that untreated Borderlines are statistically likelier to commit adultery than are non-Borderlines. However, in the case of untreated Borderlines, the emotional instability and abandonment issues make the "cheating" far less surprising. Something else that might be recurring among a disproportionate number of Borderlines is "serial monogamy." Again, the Borderlines who have had the most successful long-term relationships have consistently been those who have been diagnosed with BPD and have remained committed to their treatment.  Rather than boasting that one is a big-shot real-estate investor, one might consider the gains that come should one invest in a return to psychiatric care.

One book on the subject I recommend

For a true-life case study in all the symptoms described, read this post.

Copyright (C) 2010 Stuart K. Hayashi