The Stable Instability of Patients with Borderline Personality Disorder and the Difficulty Clinicians Face Trying to Treat Them

One of the most challenging psychological disorders for a therapist to treat and among the most resistant to therapy, Borderline Personality Disorder features a number of pathological symptoms including suicidal and parasuicidal ideation, impulsivity, aggression, dysphoria, sensitivity to abandonment, identity disturbance, instability, and angry affect (Grube, 2007). These symptoms present themselves with varying degrees of severity depending upon the patient’s type and level of BPD dysfunction. In a 1968 behavioral study of ego functions, clinical psychologists Roy Grinker, Beatrice Werble, and Robert Drye conducted cluster analysis research to identify four distinct types of patients afflicted with Borderline Personality Disorder. According to their findings, these four subgroups comprising BPD appear to occupy a continuum of decreasing severity on the border between psychotic and neurotic psychopathology. Among all four subgroups, leading features of BPD are “stable instability” (Schmideberg, 1959), “panneurosis”’ “pananxiety”, and “pansexuality” (Knight, 1953). Residing nearest the psychotic border, the BPD Type I subgroup displays features such as quasi-psychotic thought, manipulative suicide efforts, and countertransference difficulties (Zanarini et al., 1990). Type II is characterized by a pervasive pattern of instability within interpersonal relationships. Typically, these Type II patients display several dysfunctional behaviors such as self-mutilation, excessive demands/entitlement, and expressions of concern about abandonment/engulfment and annihilation (Zanarini et al., 1990), in their effort to avoid real or imagined abandonment, separation, loss, or rejection. Type III BPD sufferers show a generalized lack of personal identity, appearing to be immensely challenged at maintaining a stable or consistent sense of themselves as individuals, tending to borrow an identity from others. Chessick (1987) noted a “well-hidden poverty of genuine emotional relationships behind an attractive and personable social façade” (p.532). Type IV Borderline patients – exhibiting various traits indicating countertransference difficulties and treatment regressions (Zanarini et al., 1990) – make up the subgroup closest to the neurotic border (Gabbard, 2005). The borderline patient’s suffering is a relatively stable and enduring condition (Chessick, 1979). Often, a BPD sufferer’s emotional dysregulation leads to an uncontrollable outward volatile affect. Such a sudden shift in affect typically reflects disillusionment with a love object, and indicates the patient’s expectation of impending abandonment. Impulsivity is another characteristic signpost of the disorder. Paul, Schroeter, Dahme, and Nutzinger, 2002 found that typical expressions of impulsivity on the part of the BPD patient include binge eating, self-mutilation, substance abuse, unsafe sex and reckless driving (Zanarini et al., 2007). The patient with BPD often dramatically changes career goals, values, sexual identity, and friends (Gabbard, 2005). While in a crisis of instability a patient may inexplicably quit a job, withdraw socially, and isolate entirely. Such an impulsive and chaotic temperamental display leads to anxiety, guilt, and self-loathing for which the patient may choose to engage in high-risk or self-harming behavior in order to feel relief. These patients are known to have chronic suicidal ideation and often engage in self-harm through acts of cutting or burning (Blatt & Levy, 2003; Clarkin, et al., 2006). The BPD patient who uses cutting, burning, food, drugs, alcohol or other self-injurious behavior may obtain at least temporary pseudo-relief from feelings of self-hatred, lassitude, emptiness, and seemingly intolerable loneliness. All too often impulsive marriages and divorces, unexpected pregnancies and abortions, the perpetual starting and stopping of jobs and academic careers, spoiled successes, and blighted relationships coalesce and contribute to the failure of a promising life and even suicide (Blatt & Levy, 2003; Clarkin, et al., 2006; Lilienfeld, 2012; Linehan, et al., 2006; Wenzel, et al., 2006). Inappropriate or out of proportion expressions of anger are a distinguishing feature of BPD. Although the patient may be high functioning, efficient, and display socially acceptable conduct most of the time, the inevitable outbreak of a regressed or childlike state of helpless anger -- observed clinically by Knight (1953) and, later, Kernberg, (1975) -- devastates interpersonal interactions (Clarkin, Yeomans, & Kernberg, 2006; Gabbard, 2001, 2005; Grinker et al., 1968). At times, inappropriate anger can escalate into physical confrontations, explosive rages, and violence. BPD is widely known to interfere with interpersonal relationships. Patients’ unrealistic relational expectations with others lead to devaluation following initial idealization. The patient’s behavior often has a profoundly negative impact on family members (Hoffman et al., 2005). For example, the patient’s inability to exhibit self-control may lead him or her to take a vindictive and rageful reproach (Linehan, 1993) for perceived slights. Family members may be witness to out-of the-blue tantrums with pronounced volatility (Hoffman et al., 2005). Family and loved ones of the patient feel unable to stop or help the patient who appears to explode outwardly and implode inwardly. Commonly, such a patient struggles with a life descending into chaos and a desire to die resulting from feelings of ineptitude, subservience, and self-loathing for his or her perceived inability to self-actualize (van Reekum, et al., 1993; Wenzel, et al., 2006). Koenigsberg & Siever (2000) found evidence that BPD patients may enter a dissociative state and attempt to gain relief through self-harming behavior in order to expiate feelings of non-existence. This finding was consistent with Marsha Linehan’s research (1993). Although deeply unhappy, it is usually only during a time of crisis that the BPD patient is most likely to seek clinical intervention and treatment (Linehan, 1993). The patient with a BPD diagnosis who is in crisis is usually suffering from actual or perceived rejection or separation (Clarkin, et al., 2006). The patient’s intense dysphoria, irritability, and anxiety may vacillate in a noticeably reactive mood -- shifting in intensity, duration and frequency within hours, and on occasion can last for several days (Blatt & Levy, 2003). Depersonalization is known to occur (Zanarini and Frankenburg, 2008) during times of transient paranoid ideation and extreme stress. These feelings of depersonalization usually last from a few minutes to a few hours, and the real or imagined return of a caregiver’s affection and attention may allow the symptoms to spontaneously remit (Clarkin, Levy, et al., 2007; Hallquist & Pilkonis, 2012; Kreisman & Straus, 2010; Watson & Sinha, 1998; Westen, Gabbard, & Blagov, 2006). Patients diagnosed with BPD notoriously pose challenges to therapists seeing them in clinical practice (Adler, 1979; Gabbard, 2000; Levy, Clarkin, Yeomans, Scott, Wasserman, & Kernberg, 2006). Marsha Linehan (1993) reported that it is not uncommon for those with the disorder to storm out of sessions, make frequent calls to therapists between scheduled sessions, and blame therapists for hurting their feelings. Linehan further states that a patient’s fear of rejection by the therapist often leads to noncompliance, a decreased probability of establishing a sound therapeutic alliance, a negative outlook on the therapy process, premature discontinuation of treatment, and a poor prognosis. The rapid cycling of alternating moods and the tendency of BPD patients to inappropriately cross personal boundaries (Gabbard, 2005) can prove challenging and frustrating for a therapist. Patients entering into therapy at the height of crisis often awaken the therapist’s counter-transference response to protect and rescue. However, the patient’s characteristic tendency to idealize and, subsequently, despise others typically triggers some therapists’ intense feelings of disappointment and anger. The volatile dynamic that these patients create is likely to stem from increased sensitivity to criticism and perceived slights (Clarkin, Yeoman, & Kernberg, 2006), which heightens the patient’s instability in sense of self. Compounding these problems further is the sufferer’s chaotic use of medical and psychiatric services (Bateman & Fonagy, 2003), refusal to comply with taking prescribed medications (Gabbard, 2005), and overall noncompliance resulting in the reputation of the patient with BPD as being difficult to treat. The life threatening and debilitating effects of the disorder represent a serious public health and clinical concern (Bateman & Fonagy, 2003). That said, this group is not so much defined by therapists for their symptoms, but rather the characteristic problems underlying the symptoms, as well as the ramifications of their behavior upon others (Clarkin, Yeoman, & Kernberg, 2006). Although no single factor is known to cause the disorder, research conducted by Skodol et al. (2002) suggests contributing factors that may amalgamate, leading to the etiology and onset. Zanarini and Frankenburg (1997) propose that an inherited vulnerability (Masterson and Rinsley, 1975), a particular temperamental constellation (Cloniger et al., 1993), early childhood trauma (Paris, 1998), subtle changes in the patient’s neurobiology (Coccaro and Kavoussi, 1997; Coccaro et al., 1989; Siever and Davis, 1991), and disruptions to hormonal balance (Gabbard, 2005) may coalesce, resulting in BPD. Inconsistent and unstable patterns from caregivers during childhood (Zanarini and Frankenburg, 1997) may result in a “limited behavioral repertoire” and result in dysfunctional compensatory strategies aimed at affect regulation and emotional containment.