By Jamie Talan. STAFF WRITER
Symptoms Of Borderline Disorder
Psychiatrists describe borderline personality disorder as one of impulsivity and
"emotional dysregulation," including at least five of the following symptoms:
Frantic efforts and extreme measures (such as stalking) to avoid abandonment.
Frequent conflict with others, unstable, stormy relationships. Black- white thinking, with
difficulty seeing the "gray" of situations or compromising.
Unstable self-image, shifting from feeling confident to feeling evil or nonexistent.
Self-damaging, impulsive behavior such as substance abuse, binge eating, anorexia-bulimia, reckless spending, gambling, reckless driving (road rage) or behavior that can
lead to serious consequences.
Frequent suicidal thoughts, threats and attempts, or self-hurting, self-mutilating behavior
such as cutting or burning.
Intense emotional instability, rapidly changing short-term moods and anxiety.
Chronic feelings of emptiness, sadness or depression.
Intense inappropriate anger that may lead to physical fights or destruction of property.
Stress-related dissociative symptoms such as paranoia; feeling as if one is losing touch
with reality; feeling victimized; unable to accept responsibility.
Sara Grayson was as graceful on the slopes as captain of Brandeis University's ski team as
she was on the stage captivating audiences in the lead role of the Gilbert and Sullivan
operetta, "The Gondoliers." She made life seem easy. She'd spent her junior year in
Spain, kept a steady academic pace on the dean's list, joined an a cappella group and had
been accepted into a graduate psychology program at Columbia University that was to
begin this fall.
But only a few months after graduation from Brandeis, Grayson' s charmed life began to
crumble. She became deeply depressed, bulimic and suicidal. And on Sept. 24, any hopes
for Grayson's future were dashed when she wrote her parents and sister a suicide note,
then went into a closet at an outpatient psychiatric residence in Westchester and hanged
herself.
Grayson, from Vermont, is one of a growing number of young men and women diagnosed
with a baffling and potentially fatal psychiatric condition called borderline personality
disorder. The disease is marked by impulsivity, unstable relationships, outbursts, self-harming behavior and mood disturbances. Until recently, few therapists would take on
patients like Grayson because there was no effective treatment, and they feared the
patients wouldn't get any better and might even kill themselves. More than 70 percent of
these patients engage in self-harming behavior, and one in 10 commits suicide. While the
government has sponsored epidemiological studies to assess how common certain mental
disorders are in the general population, it was only last year that borderline personality
disorder was included. And the results - one to two diagnosed per 100 people questioned -
suggest that it is as common as manic-depression and schizophrenia.
Now federal agencies and private organizations are waking up to the seriousness of the
illness, according to Dr. Larry Siever, a psychiatrist at Mount Sinai School of Medicine.
They're providing funds to study its development, course and treatment in an attempt to
understand people who, like Grayson, act on suicidal thoughts. "This is a very serious
disease, " said Siever, whose brain-scan studies have shown the first hints of a biological
abnormality.
But while scientists are beginning to unravel the biology of the disorder, hospital-based
treatment programs remain scarce.
"It's a problem," said Dr. John Oldham, former director of the New York State
Psychiatric Institute and an expert on personality disorders. Many patients end up going
in and out of psychiatric hospitals and emergency rooms. Oldham, who recently moved to
the University of South Carolina, says that the patient scars and suicides and advances in
understanding the disorder' s biology have spurred scientists to wage a war against the
condition. Last year the American Psychiatric Association developed practice guidelines, a
map for professionals treating these patients, and a flurry of research papers has been
published in respected journals.
Borderline patients have long been seen as "difficult" and "manipulative, " Oldham said,
and hospitals and psychiatrists shy away from taking them on as patients because of the
high risk for self-harming behaviors. "But things are rapidly changing," added Oldham,
who spoke to a packed audience at the American Psychiatric Association's recent annual
meeting in Philadelphia.
The condition was named more than 30 years ago by psychiatrists treating patients who
weren't responding to traditional therapies. The term "borderline" was coined because
the patients were neither psychotic nor neurotic, Oldham explained, and it seemed that
they fell somewhere in between. In recent years doctors and patients have argued that the
name doesn't say anything about the nature of the illness.
The new war on borderline personality disorder can be traced to an international
research foundation overseen by New York City lawyer Marco Stoffel. The Borderline
Personality Disorder Research Foundation has two Nobel laureates on the board of
trustees - Rockefeller University's past president, Dr. Torsten N. Wiesel (chairman of the
foundation), and Dr. Eric R. Kandel of Columbia University. Dr. Steven E. Hyman,
provost of Harvard and former director of the National Institute of Mental Health, is also
on the board. The foundation has hosted two scientific meetings in the past year and is
coordinating research at six major universities in Europe and America.
In 2000, NIMH devoted 1 percent of its budget to all personality disorders, $5 million of
which went to borderline. (Other conditions include antisocial, narcissistic and paranoid
personality disorders.) This year, that funding has tripled.
One of the most promising new treatments, known as DBT, for dialectical behavior
therapy, was designed by Marsha Linehan of the University of Washington. Linehan
spent decades testing behavioral strategies on people who had attempted suicide several
times. DBT focuses on behavior, helping the person change patterns of impulsivity that
lead to self-harm.
"It is at its best with suicidal behavior, which is no small thing, " Linehan said.
Psychodynamic psychotherapy, a technique designed to rework one' s long-held ideas
about one's self, one's relationships and environment, has been used for decades without
empirical evidence of success. Studies are now under way to test whether it does work.
Weill Cornell Medical College is teaming up with Harvard researchers in a three-year, $3
million study to compare DBT, supportive treatment (following a patient and providing
standard talk therapy) and psychodynamic therapy. About 120 patients will be recruited
for the study. Siever of Mount Sinai also is conducting brain-scan studies, as are scientists
at Yale University.
At Harvard, psychologists will be conducting studies of memory, attention, emotion and
personality processes in an attempt to unravel the biology of the illness.
At the New York State Psychiatric Institute in Manhattan, Barbara Stanley has recruited
30 suicidal borderline patients for a five-year study comparing Prozac, DBT, supportive
psychotherapy and combination therapies. She decided to focus on borderline patients
because they don't fit the typical model of people who try to kill themselves. "They may
get suicidal over a breakup of a 1-month-old relationship," Stanley said. Other "people
don't understand, and they think they are acting and manipulative. But these people can
fall apart real fast and come together quickly."
Some research suggests that borderline patients have abnormal pain perception, and that
cutting or otherwise injuring themselves may trigger brain chemicals that actually make
them feel better, according to Dr. Mark Russ of Long Island Jewish Medical Center. He
said that on tests at least 50 percent of patients underreport the experience of pain. Brain
scans also show that electrical waves are slower in patients who don't seem responsive at
normal pain thresholds.
Psychiatrists are even debating whether the borderline condition qualifies as a personality
disorder. Many believe it is more akin to mania and depression, which are mood
disorders.
"These are patients in an enormous amount of psychic pain," said Dr. John Gunderson, a
Harvard Medical School psychiatry professor who directs the outpatient borderline
program at the school's McLean Hospital.
The borderline patient has problems balancing emotional life, Gunderson explained. Such
a trait could be genetic, though stress in the environment could exacerbate it. Researchers
cite growing evidence of the existence of brain systems that regulate the ability to stop
doing something harmful or dangerous.
Borderline patients often complain of feelings of emptiness and as a result seek out
immediate attachments and become overly dependent, Mount Sinai's Siever said. For
decades, such patients would enter long-term in-patient programs to undergo
psychodynamic psychotherapy and cycle in and out of the hospital every time their world
fell apart.
But such an approach was lost to managed-care cuts, doctors say. Now patients may enter
the hospital after a suicide attempt, but doctors say they are released before effective
treatment can be determined.
A growing number of doctors is finding outpatient programs more effective, but such
programs are in limited supply.
"Patients need to learn how to live in the world, not just in a hospital environment,"
Linehan said.
"It's not about altering personality but changing behavior," said Dr. Charles Swenson, a
Massachusetts psychiatrist who brought DBT to the New York- Presbyterian Hospital's
Westchester campus in the early 1990s.
"Over time, I came to believe that we needed to address these behavioral deficits,"
Swenson recalls. "Patients needed to know what to do when they were angry, ashamed or
sad. They needed to know how to act in a relationship - in their personal lives and at work
- when things went wrong.
"The idea was to teach patients to stop hurting themselves and to develop a quality of life
that was not conducive to suicide."
Where to Find Help, Information
For more information on borderline personality disorder:
www.borderlineresearch.org,
or www.bpdcentral.com.
Treatment and Research Advancements Association for Personality Disorder has
information for New York City families at www.tara4bpd.org.
National Education Alliance for Borderline Personality Disorder, created by DBT
psychologist Perry Hoffman, 914-835-9011, or www.borderlinepersonalitydisorder.com. -
Jamie Talan
SOURCE: Treatment and Research Advancements Association for Personality Disorder
Jamie Talan, A Baffling Diagnosis / New attention is being paid to borderline personality
disorder - an ailment that sometimes ends in suicide. , Newsday, 08-05-2002, pp D01.
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