Borderline – Borderline Personality Disorder

Hello friends!

I received some requests to talk about Borderline Personality or as it is also called around here – Borderline Personality Disorder. The translation of Borderline into Borderline is quite accurate and, if we think about it, we will see that it makes perfect sense because the center of this psychic disorder is precisely the concept of limit or “edge line”. However, as the most used term is Borderline, we will use only this term in the text.

ICD-10, the International Statistical Manual for Illnesses (mental and non-mental) classifies Borderline Personality Disorder as a personality disorder that is characterized by impulsiveness and instability of affects, interpersonal relationships and self-image or self-image. In addition, the person who is diagnosed with this disorder presents great idealization alternating with great devaluation of other people, not infrequently having symptoms of self-harm and suicide attempts.

As we know, the suicide attempt and thoughts about one’s own death make a mental illness a type considered more serious, since the individual can unexpectedly end his life.

The DSM-IV, which is another reference manual for the classification of illnesses (in this case, especially mental illnesses) reports that Borderline Disorder affects 2% of the world’s population. In outpatient clinics, this number reaches 10% and in psychiatric patients admitted to institutions, this number can rise to 20%.

In general, this disease is noticed in early adult life, when there is precisely the greatest risk of a suicide attempt. After the age of 30-40, the risk drops, with normally greater personality stability, with a decrease in symptoms.

Let us then see the list with the Diagnostic Criteria, according to the DSM-IV, and then I will comment on each one of them.

Diagnostic Criteria for Borderline Disorder

A pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of settings, as indicated by five (or more) of the following criteria:

(1) frantic efforts to avoid real or imagined abandonment.
Note: Do not include suicidal or self-harming behavior covered in Criterion 5

(2) a pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation

(3) identity disturbance: marked and persistent instability of self-image or sense of self

(4) impulsivity in at least two potentially self-damaging areas (eg, financial spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-harming behavior covered in Criterion 5

(5) recurrence of suicidal or self-mutilating behavior, gestures or threats

(6) affective instability due to marked mood reactivity (e.g., episodes of intense dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of irritation, constant anger, recurrent body fights)

(9) transient and stress-related paranoid ideation or severe dissociative symptoms

Commentary on the DSM-IV Criteria

(1) frantic efforts to avoid real or imagined abandonment

People with Borderline Disorder do everything they can to not feel abandoned. The DSM-IV cites some situations in which this attempt not to be abandoned by another person takes place. For example, when the psychologist or psychiatrist is about to end the session, inappropriate reactions arise in order for the session not to end. In this case, the end of the session is seen as an (imagined) abandonment.

Other similar situations happen, reaching the point where the individual pretends to attack himself or someone else when he feels he is being left – even if it is only for a few moments.

(2) a pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation

This is one of the most important criteria that distinguishes it from other personality disorders. In general, there is an extreme appreciation of the other at the beginning. When the other does not meet exaggerated expectations, the borderline person starts to devalue the object that, shortly before, was overvalued. In summary: “These individuals are prone to sudden and dramatic shifts in their views of others, who may be seen alternately as benevolent supports or as cruelly punitive. Such changes often reflect disillusionment with a person whose qualities of devotion have been idealized or whose rejection or abandonment is expected.

(3) identity disturbance: marked and persistent instability of self-image or sense of self

The borderline individual may present constant changes in his identity, that is, in who he thinks he is and what he thinks he should do. As a result, there is great instability in general opinions about themselves and the world, frequent changes in professional activities, sexual interests, values ​​and groups of friends.

(4) impulsivity in at least two potentially self-damaging areas (eg, financial spending, sex, substance abuse, reckless driving, binge eating).

Excluding direct self-harm in this item, the person with the disorder injures himself in two or more situations that are likely to be inappropriate for his health or quality of life. There may be use and abuse of chemical substances (drugs), sexual or food compulsions, impulsiveness and destructiveness in your financial management, driving on the limit, among others.

(5) recurrence of suicidal or self-mutilating behavior, gestures or threats

Self-mutilation has been a symptom that we have noticed with increasing frequency in the office. Teenagers and even children have had this type of behavior, such as, for example, cutting their arms or legs with a stiletto or razor blade. It is important to note that the symptom of self-injury does not necessarily mean a suicide attempt, nor can it, as an isolated symptom, be a criterion for Borderline Disorder. In this, there is a constant recurrence of attitudes that tend to suicide and, also, frequent episodes of self-mutilation.

(6) affective instability due to marked mood reactivity (e.g., episodes of intense dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

As we saw from the beginning, exacerbated emotional instability is a symptom that defines what the Borderline concept really is. In the DSM-IV, we find a summary of this sixth criterion: “The basic dysphoric mood of individuals with Borderline Personality Disorder it is often disturbed by periods of anger, panic, or despair and is rarely relieved by periods of well-being or contentment. These episodes may reflect the individual’s extreme reactivity to interpersonal stresses.

(7) chronic feelings of emptiness

This criterion is easy to understand and there is no need to dwell on it.

(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of irritation, constant anger, recurrent body fights)

The key to understanding this criterion is the inability or great difficulty in controlling anger. Anger, as a universal human emotion, appears and can appear to everyone. But in the case of the borderline person, the tantrums are due to situations that would not be considered important, that is, they would be considered by other people as inappropriate, in addition to having great intensity, the borderline person cannot contain it.

(9) transient and stress-related paranoid ideation or severe dissociative symptoms

In very stressful situations, the individual may have paranoid symptoms, however, these episodes are generally brief and do not indicate the need for an additional diagnosis (of psychosis). That is: “These episodes most commonly occur in response to real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caring person’s affection can lead to a remission of symptoms”.

Finally, for a diagnosis of Borderline Disorder to be made, five or more of the above criteria must be present.

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