Thread by @drjanaway

BORDERLINE/EMOTIONALLY UNSTABLE PERSONALITY DISORDER THREAD

I hope to cover and explain this diagnosis using a range of sources and explanations, some of which will have a personal understanding to the terms. If you feel I have missed anything, please add your thoughts.

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Definition: The major definitions of EUPD/BPD come from either the Diagnostic Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD.) They overlap considerably, so the DSM's BPD can be closely understood as ICD EUPD.

The ICD (10) describes EUPD as a persistent disorder of acting impulsively, unpredictable and extreme mood changes, emotional outbursts, impulsivity, problems with identity, intense relationships with extremes in attachment, and self-risking behaviour.

THE DSM (V) expands on these aspects a bit more, suggesting a person must have at least five of the following to fulfill a diagnosis (abridged)

1) Frantic efforts to avoid real/imagined abandonment
2) A pattern of unstable/intense relationships, swinging between love and hate

3) Identity disturbance, which is marked and prolonged in self-image and sense of self
4) Impulsivity in two areas that are potentially self-damaging (substance misuse, binge eating etc)
5) Recurrent suicidal behaviour, gestures, threats or self-harming behaviour

6) Mood instability and enhanced reactivity
7) Chronic feelings of 'emptiness'
8) Inappropriate or intense anger or problems controlling it
9) Transient, stress-related paranoia or dissociation

It is worth noting two critical points here already, and many of you would have spotted them

1) All of these symptoms can occur in other illnesses, or as reactions to events. It is the duration and constellation that matters
2) A different diagnosis must be excluded.

As you can read, the DSM provides a little more detail than the ICD, but essentially the same tenets are there, which are, in my own definition: a chronic and complex adaptation to problems with sense of self and relationships leading to intolerable moods and resultant behaviour.

What this means is that many of the symptoms we see above are reactions to underlying problems developed within the development of the psyche, and the result present as recurrent patterns of behaviour that have some adaptive function, but end up being harmful.

For example, intense anger is rational, but intense anger based on a perceived slight or fear of being judged usually is not, and crucially the person can see this later. This anger serves a protective mechanism, but it is blunt and over-reactive.

I will cover defenses in another thread, but they are crucial the diagnosis. If we consider the borderline personality operationalisation (a psychodynamic term,) we can see two major defenses at play

1) projection
2) splitting
3) forms of aggression (passive/active)

These are argued to be of an 'unconscious' motivation, that is the person is not aware of it (Freud) and it manifests in a behaviour or perception that is based on the persons perceived reality, not the real one. However, the person has some insight to this later (non-delusional)

Projection is placing ones own internal emotion outward, i.e onto someone else. I feel guilty, so this person must be. The feeling of guilt may or may not be conscious, but the process of projection is not known to the person.

Splitting is a more complex mechanism whereby the person is unable to balance both the good and bad aspects of a person (i.e the external object) and thus splits it into good or bad. At the same time, they split themselves into good and bad to maintain this process.

An example would be that 'someone is all bad' and 'i am bad with them' or 'this person is all good' and 'they are good for me, I am always good with them.' These thoughts do not allow for grey areas. This is known as idealisation and devaluation

We can see an example in an unstable relationship, at first the person is split into 'all good' and 'losing them' is 'all bad.' 'All bad' in this case, is total annihilation, the end of all things. So losing them is death on an unconscious level.

Once the person disappoints, which they often will either because it is human, or there is an element of projection occurring, the switch to 'all bad' occurs. But at the same time the fear of abandonment is still there and active. Its a tug of war between two extremes.

You may have noticed that these behaviors seem childlike, and that's because they developed as a child. The unconscious brain is very infantile, its developed under the threat of complete annihilation when the baby is extremely vulnerable.

Splitting is so early on that some argue it occurs before the infant even develops a real sense of its impact on things and people, so by nature the intense behaviours are linked to ideas of life and death. For a crying infant this is useful, for an adult it is not.

This does not mean EUPD patients are children, or juvenile, it means they, under periods of stress or due to trauma etc, will operationalise this survival mechanism in day to day life. But why do they need it?

Causes: Any 'cause' of illness is complicated. We tend to think about the biopsychosocial, that is which causes are inherently biological (genetic, physical, chemical,) psychological (learned, experienced, reactive) or social (as a result of external changes or expectations.)

Quickly you can see that the three areas cannot be easily separated, anything that causes a social pressure will have psychological results and physical symptoms. Anything that has psychological trauma will result in social changes,

I will also remark here that although we have a diagnostic syndrome for EUPD, many of the symptoms provided above only stand out due to their social determinant. If self-harm was viewed as helpful it may not feature. And splitting is present in most people very often.

The line between what is a socially derived 'difference' in behaviour and what is 'illness' is a complex one, and at the extreme you can argue there is no such thing. But if you are there is such a thing, i.e something that will be helped by treatment, you need to define it.

Biological: evidence exists in twin studies of a heritability of extroversion vs introversion, with some data showing tentative links between multiple genes acting together to influence personality. The significance of this is minimal here.

Psychological: for EUPD, this is the major cause and has multiple explanations that I will attempt to explain and bring together. Childhood trauma, early sexual abuse, and disorganised attachments are the major explanations which I will treat individually and then coalesce.

When we consider early infantile development, depending on whether be believe the ego (mainly conscious sense of self mediating the internal drives and external rules,) is present at birth, we can see trauma impacting in the same way,

At the early stage of development, an infant sees the world mainly as 'life or death' (the splitting phenomenon) and cannot seperate itself (the internal object) from the external world (external object.) As such, it believes it is all powerful but also vulnerable.

The omnipotent infant believes that its pain is caused by the external, i.e hunger by the absence of mother, and that crying actively brings mother to feed, not influences. This is early grandiose thinking. In such states the mother is all good or all bad, as is the world.

As the infant grows it learns to differentiate itself from the world and its rules, tolerate ambivalence to itself and objects, and learn cause and effect more readily in a more congruent and realistic way. This is limited by cognitive development too.

If this process is interrupted in early childhood, often by something traumatic, especially sexual, it is interrupted (arrested, stunted, etc.) The child may go on to develop, but the defense protocols present at the time of interruption persist, especially under stress.

So if we consider personality as someone's psyche, reactions and impact of the world and behaviour/thoughts about it, this will be coloured by the early arrest. The leaving girlfriend is the same as the murderous mother, but we cannot bear her to leave.

None of this is logical, but it does not need to be, as the infant is not logical, it is surviving. The key thing here is that the person is aware when challenged of the logical fallibility of their belief, they do not lose contact with reality.

Admittedly this is a brief simplification, but it serves a purpose. If we consider EUPD as the result of early trauma, we can better understand the person as a survivor or something life-threatening that the mind refuses to give up. This is what makes it an illness.

Attachments are an extension of this, i.e a secure attachment is one built on ambilavance, the primary care giver is seen as safe, but also not always reliable, their absence can be tolerated. An insecure attachment is the opposite, and 'disorganised' is indicative of trauma

'disorganised' means the relationship pattern appears dominated by whim, is disproportionate, and holds the shadow of splitting, intense fear, emotional liability and terror, as well as intense moments of idealisation and connection.

This is an abused child, one who has not been able to develop, who has seen a perception of annihlation, abuse or intrusion so deep it has interrupted the very process that allows development of relationships beyond the early grandiose/paranoid.

So if we bring the psychological ideas together, they all hinge around the same idea, the break in development caused by intense trauma that leaves the child with a difference in personality and relationships, and the symptoms are the result.

So how do we diagnose it? Firstly, not on one meeting, in the presence of a severe trauma, or indeed if another diagnosis explains the symptoms. By its definition. eupd is a long-term illness, and tends to become noticed when social factors change.

The childlike aspects of behaviour become noticeable in adult life, or when the stressors of social interaction become more complex, or when a holding figure leaves. It has to have gone on a while, and be severe, to be a disorder that suggests an actual illness.

We also need to find an explanation, is there a previous trauma? If so, how do we define its significance? Some trauma is so repressed by memory it will never be found apart from the shadow it has left. Sometimes we may find none at all.

The crucial thing here is that we cannot always explain everything, but over large groups of people the same causes, symptoms and patterns emerge. That said, we need to be very careful, and assessment for EUPD should take a long time.

Treatments: There are multiple treatments, and the major ones are psychological. The methods of these treatments are not my expertise, but dialectal behaviour therapy and CBT can be useful for different parts of the disorder.

Longer-term more dynamic therapy can be helpful, but it must be used with extreme caution. By nature, psychodynamics illicits cause and treatment by the buried, and the buried does not like being awoken. It is within analytics like this that EUPD was first really explained.

Medications can be helpful, but must be understood and used in balance. SSRIs can be helpful for anger and associated depressive episodes, but run the risk of increasing impulsivity. Antipsychotics can help reduce mood fluctuation. But these are not cures.

Further more, any medication has side effects, so the good has to be weighed against the bad. In the end time and individual experience will tell us a person's actual benefit, but the gross numbers do suggest they help if used correctly.

Stigma: EUPD/BPD has a large stigma around it, and when we review the symptoms many of use can imagine why that could be, its not helpful, its difficult, and being the external object could be exhausting, painful, make us feel insecure, paranoid, all powerful or vulnerable.

Perhaps you have noticed something here, the idea of projective identification, projections twin, you feel and identify with what the person feels. This is the root of stigma, our own intolerability to the intolerability the patient feels. It is empathy, but we cannot see it.

It is hard to treat EUPD, and people should not be blamed for how their unconscious mind reacts to the external world. That does not mean that they bear no responsibility for their actions, but it does mean we can try to help them understand and manage them if they choose.

The key takeaways here

1) EUPD is a primarily psychological disorder caused mainly by early trauma
2) The effect on psychosocial development is profound and unconscious defenses persist in a strong way
3) The symptoms seen represent this, and make life very difficult for them,

4) The impact on relationships due to this make life harder
5) It can be treated in multiple ways, and these can be very effective
6) Stigma makes it worse, and reflects more on you than them.

Hopefully this covers what I promised to cover. It is a divisive topic..

I realise that being outside of having it myself there is a risk of misconstruing or docsplaining experiences, so consider me trying to do the right thing. If there is anything you wish to add, educate me on or point out, please do. And please #retweet.

Sources

DSMV,ICD10,Oxford shorter textbook of psychiatry, freud standard editions, an introduction to object relations, various psychodynamic texts.

Caveats:

I am still learning.