It has been my experience that whenever any patient is diagnosed with borderline personality disorder (BPD) in Delhi, the treating team usually comprising of a clinical psychologist, psychiatrist and a social worker feel quite hopeless. There is a widespread myth that a person suffering from Borderline Personality Disorder cannot be treated. Further, psychologists and psychiatrists erroneously believe that borderline personalities tend to fake symptoms and are not motivated to change. These faulty beliefs stem from lack of training and experience in understanding and treating personality disorders. Personality disorders are not like regular psychiatric disorders where the person experiences symptoms but the damage is deeper and pervasive. If the treating psychologist knows how to identify and address this damage, there is tremendous hope for the one suffering from Borderline Personality Disorder (BPD).So, let us understand this enigmatic condition.

What is a personality disorder?

First and foremost let usrecognize the nature of a personality disorder. All of us have a distinct personality; no two people are the same. 'Personality' comprises ofmore or less stable ways of thinking, feeling, behaving and relating to others.Personality defines who we are across situations. Generally, our personality helps us in striking a balance between our inner reality and the requirements of the society.

While some people strike a workable balance, there are others who cannot. Some people are so preoccupied by their inner reality that they ignore the outside world; while there are others who cater to outside reality by suppressing their inner self. When someone's personality is so rigid or so marked by deficit that they have persistent problems in living, we may call it a personality disorder. Typically, when our ways of thinking, feeling, acting and being with others repeatedly cause pain to ourselves or to others, or become preoccupying they may constitute a personality disorder. There are several types of personality disorders and borderline personality disorder is one amongst them.

What is Borderline Personality Disorder? - Symptoms and patterns

In my experience as a psychologist with various borderline personality disorder (BPD) patients, what appears abnormal or crazy from the outside has important logic which we can understand once we develop psychological skills and patience. Generally a person suffering from Borderline Personality Disorder has few or more of following symptoms and patterns. Please note that having a single symptom on certain occasions from the following list does not mean that you have BPD. It is important to realize that the BPD person thinks feels and acts like this across situations. These signs and symptoms characterize the person's identity over a long period of time starting from young age:

. Unstable relationships: The hallmark borderline personality disorder symptom is the person's unpredictability in close relationships. People suffering from borderline personality disorder shuttle between intense love and equally intense hatred. These people fall into love intensely and quickly and their love turns into hatred at the drop of a hat. Although this may seem crazy to the other person, it has a sound inner logic. Individuals with BPD search for a perfect person whom they can blindly trust and rely upon. When they enter a relationship, they feel that have found the perfect person. However, because no one can ever be perfect, sooner or later they feel cheated and hurt. As soon as they are hurt they boil up in anger.

. Splitting everything into 'good' and 'bad':The second major BPD symptom is splitting. A majority of people learn that nothing is usually completely good or bad but everything has shades of grey to it. People suffering from borderline personality disorder symptoms have not learnt this lesson due to extremely traumatic life experiences. They want a world that can be neatly categorized into 'good' and 'bad' so that they can take everything good and keep away from everything bad. Based on this need, they try to rigidly categorize people, places, norms, values, occupations, relationships and almost everything else into either good or bad. Because nothing usually is so clearly good and bad, they suffer from frequent disappointments and get angry.

. Impulsivity:Another classic BPD symptom is impulsivity. People having borderline personality disorder feel intense psychological pain all the time and they want to divert their attention. As a result, they constantly need to do something that generates intense pain or pleasure. This makes a BPD person function on an impulse without regard for consequences. They end up indulging in self-damaging behaviours such as suicidal attempts, substance use, reckless spending, binge eating, sadomasochistic sexuality and unsafe sex.

. Identity disturbance:The fourth important borderline personality disorder symptom is markedly and persistently unstable sense of self. These people experience sudden and dramatic shifts in self-image characterized by shifting goals, values, personal and sexual identity, vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values and types of friends.

. Mood swings: Although most of us experience mood swings, in case of someone with borderline personality disorder mood swings are intense, fluctuating and rapid.To the outside world, it may appear that they can be extremely happy, sad or angry without any reason. However, once we start understanding their inner world it becomes apparent that these mood swings depend upon whether their expectations have been met or not.

. Separation anxiety:The fifth common borderline personality disorder symptom is intense separation anxiety. People with BPD are extremely disturbed by separation. They make frantic efforts to avoid real or imagined abandonment. This makes them stick to relationships, no matter how disturbed or abusive a relationship may be.

. Emptiness:Chronic feelings of emptiness and a compulsive need to fill it by something or someone is a pattern seen in many BPD patients. Easily bored, they constantly seek something to do.

. Aggression: Inappropriate and intense anger or difficulty in controlling anger is commonly seen in borderline personality disorder. Those suffering from BPD show frequent temper tantrums, constant anger, short fuse and may get into recurrent physical fights. They may display extreme sarcasm, enduring bitterness or verbal outbursts. Such expressions of anger may be followed by shame and guilt and contribute to the feeling they are being evil.The anger is often elicited when a person is seen as neglectful, withholding, uncaring or abandoning. Anger can be directed towards self or others.

Causes of Borderline Personality Disorder

Many people wonder what causes borderline personality disorder. In recent times, there has been an increasing trend to find out biological causes for all personality disorders including borderline personality disorder. However, there is a very significant role of early childhood trauma in causing BPD. Borderline personality is a deficit state preceding the formation of a stable self. As a child, the person did not get a good enough environment so that their negative emotions could be understood and worked through. The environment failed to provide empathic response that a child needs to overcome distress. Borderlines have unmet needs to be admired, supported and understood. In all their adult relationships, they seek fulfilment of these childhood needs. Rage is simply a reaction and emerges when others are felt to be unavailable, disappointing or frustrating.

Borderline Personality Disorder- Tests and diagnosis

When someone feels that they may have BPD, they often wonder what are the available, valid and reliable tests to diagnose borderline personality disorder. Several self-report questionnaires and tests have been developed to diagnose whether someone has borderline personality disorder or not. However, most of the tests that claim to diagnose BPD do not give reliable results. This is because a BPD person may not have adequate insight to understand and report the extent of their dysfunctional patterns.

Also, various borderline personality disorder tests focus on observable symptoms and neglect deep-seated patterns that are crucial in diagnosing borderline personality disorder. Some psychologists in India also use projective tests such as TAT and Rorschach to diagnose BPD but these tests are unreliable. The best way to diagnose borderline personality disorder is by an in-depth interview and detailed history taking. In my psychological experience, Structured Interview of Personality Organization (STIPO) and International Personality Disorder Examination (IPDE) are two interview-based tests that give a fair idea whether the person suffers from borderline personality disorder or not.

Borderline Personality Disorder - Treatment

The best treatment for borderline personality disorder is psychotherapy. Medication and other forms of treatments and therapies are only an adjunct.

. Psychiatric medication: Antidepressants, mood stabilizers and antianxiety drugs are of limited help in BPD. In India, there is a trend of medicating every borderline personality disorder patient. Medication alone never helps a BPD patient and not all borderline patients need medication. Psychiatric drugs should be given to only those BPD patients who are acutely suicidal, severely depressed or violent. The mainstay of BPD treatment is on-going psychotherapy. Generally, two types of psychological treatments have been very effective in dealing with borderline personality disorder- dialectical behaviour therapy and psychoanalytic psychotherapy.

. Dialectical behaviour therapy (DBT):DBT helps the borderline patient to observe and regulate their intense emotions through mindfulness. The person is instructed on how to comfort oneself, deal with negative circumstances and develop a healthy self-esteem. Also, robust work is done on the individual's interpersonal skills so that they can effectively deal with the various relationship conflicts that they often get into.

. Psychoanalytic psychotherapy: Three types of psychoanalytical treatments- Mentalization, Transference-focused and Self-Psychological are known to be effective in dealing with borderline personality disorder. The BPD patient is able to develop and experience a unique relationship in therapy. As a result they are able to understand various deficits and conflicts in their personality and work through them. Psychoanalytic therapy leads to a deep and permanent change in the personality of BPD patient.

The take home message is that individuals suffering from borderline personality disorder are neither bad nor mad. They are in intense pain. Change can happen once the treating psychologist or psychiatrist begins to understand their pain and not dismiss it. Once the BPD patient feels understood, they start developing trust and motivation for change.