Wednesday, October 14, 2015

Diagnosing and Treating Borderline and Narcissistic Personality Disorders, Part One: Borderline Personality Disorder

Over the past 10 or 20 years there have been increased mentions of Borderline Personality Disorder and Narcissistic Personality Disorder in the media, including newspapers, self-help books and even feature films. These disorders are complex and manifest differently in different individuals. Many times clinicians can't diagnose, or won't diagnose, these disorders in the first session or the first several sessions, especially if the person is initially depressed.

How to diagnose personality disorders remains controversial in the mental health field. The Diagnostic and Statistical Manual of Mental Disorders, the main reference book for diagnosis, uses checklists of symptoms. Is a checklist of symptoms really the most accurate way to diagnose a disorder? A checklist does not describe causes or underlying psychological processes.
The current checklist for Borderline Personality Disorder in the DSM-V, is the following ( only 5 of these symptoms need be present to make the diagnosis). One can see that there might be significant overlap with other diagnoses, such as depression and PTSD:

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
3. Identity disturbance: markely and persistenly unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentialy self-damaging.
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective (emotional) instability.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Starting in the 1970s, a psychoanalyst and researcher named Otto Kernberg began studying borderline personality disorder, a condition that had begun to be identified after the time of Sigmund Freud. Prior to the development of the term "borderline personality disorder," clinicians sometimes came across patients with what they called "ambulatory schizophrenia" or the "As If" personality. What they were trying to describe was a syndrome in which the person functioned mostly normally, and had no obvious evidence of psychosis, but under psychoanalysis or even just persistent questioning, revealed themselves to have highly distorted thought processes. Kernberg came up with a type of initial evaluation to diagnose this condition. He also developed a theory that remains controversial today. He believes that all personality disorders are subsets of borderline personality disorder, because the disorder isn't really a syndrome at all but a type of personality organization--"Borderline" refers to the border between neurosis and psychosis. "Normal" people have a neurotic level of organization (no one is completely mentally healthy), psychotic people have lost the ability to distinguish reality from fantasy, and borderlines, in the middle, remain in touch with physical reality but distort perceptions based on pathological psychological defenses. These distorted perceptions can lead to problems in interpersonal relationships and other issues. Other personality disorders, such as narcissistic personality disorder, function on the same level, but simply manifest differently due to slightly different personality development.

The subject of psychological defense mechanisms is complex. However, this explanation, taken from Wikipedia, is generally correct:

A defence mechanism...reduces anxiety arising from unacceptable or potentially harmful impulses. Defence mechanisms are unconscious and are not to be confused with conscious coping strategies "
... In psychoanalytic theory, defence mechanisms...are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses
....Healthy persons normally use different defences throughout life. An ego defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected.

Kernberg and others have found that people with borderline personality disorder often extensively use the defenses of idealization, devaluation (often combined in "splitting"), grandiosity, and types of projection.  But use of these defenses often are not apparent to the casual observer, and, because defenses are unconscious, the borderline person remains unaware of their own use of these defenses.

Although I believe Kernberg's theories to be mostly correct and especially helpful in terms of formulating a prognosis, like many psychoanalytic theories, it doesn't really address the issue of later environmental factors (Kernberg believes that early environmental factors combined with genetics are at the root of personality disorders). Starting about 20 years ago, theorists began to notice that the typical symptoms of persons with borderline p.d. were quite similar to those of trauma survivors and suggested that some borderlines might actually have PTSD and had been misdiagnosed. But one could say that this is the very reason why Kernberg's perspective is  important, because it emphasizes the underlying defenses rather than the overt symptoms.

Earlier this year I went to a talk by Dr. Michael Stone, the forensic psychiatrist, in which he suggested clinicians decide whether the borderlines with whom they were working had primarily a trauma-based condition or primarily a genetic condition. I've begun to believe that there are different types of borderline p.d. Perhaps eventually diagnostic manuals will reflect what clinicians have been seeing for many years.

How is borderline personality disorder treated? Some would answer, not well. The general consensus is that the disorder is resistant to change. However, there are a multitude of treatments that may help. Traditionally the disorder has been treated with intensive psychotherapy to address the pathological defenses. The underlying premise of this treatment is that human personality is malleable, is developed in an early dyadic relationship, and can be altered by the patient/therapist dyadic relationship even in later life. I believe this to be somewhat true. In the 1990s, a psychologist named Marsha Linehan developed a treatment protocol called Dialectical Behavior Therapy to help borderlines learn to cope with their emotions and interpersonal relations. DBT is now used to help people with other disorders as well.  I occasionally use DBT techniques, as they help people learn assertiveness as well as distraction techniques, especially "mindfulness," to relieve overwhelming emotions. I have found people with anxiety disorders often benefit from DBT.  The DBT program does not really alter the underlying personality structure, however.

I've treated a number of people with borderline personality disorder, and have found them to be quite different from each other. A childhood marked by invalidating remarks by parents is common, but not everyone subjected to such an environment will develop BPD. Psychotherapy that combines validation with confrontation of unhelpful defenses seems to be useful for my personality-disordered patients. In a few cases, I've seen patients with borderline personality disorder benefit from a mood stabilizing medication called Lamictal, which moderates their unstable emotions.