While research on personality disorders looks promising, there remain so many more questions than answers about one type of personality disorder that frustrates clinicians and often defies treatment.
One woman who attended the "Ask the Doctor" session on borderline personality disorder (BPD) at the annual conference of the National Alliance for the Mentally Ill (NAMI) in July raised some of the difficult questions that accompany this disorder.
"For 12 to 14 years," said the mother, "I have been trying to provide my daughter with an answer about why she is so ill." The mother went on to describe a girl who wanted to know why she was born. A girl who felt she had a black cloud following her around, believed she was a "piece of scum" and was not redeemable by God. Her symptoms included anxiety attacks, an eating disorder, severe depression, six serious suicide attempts, and self-mutilation, according to her mother.
Siever is a professor of psychiatry and director of the outpatient psychiatry department at Mount Sinai School of Medicine in New York City and director of the Mental Illness Research, Education, and Clinical Center at the Bronx Veterans Administration Hospital.
"Sometimes [all you can do is] to be there for the patients when they experience this terrible self-loathing and help them to understand that as overwhelming as these feelings are, they are part of an illness."
According to the DSM-IV-TR, borderline personality disorder is characterized by a "pervasive instability of interpersonal relationships, self-image, and affects. . . ."
Common symptoms are promiscuous sexual behavior, self-mutilation, substance abuse, and binge eating.
There are different theories about what causes the group of symptoms or behaviors collectively known as BPD. A new possibility under study is that BPD is a brain disorder, said Siever, noting that researchers are beginning to study a vulnerability model of BPD in which a person has neurobiologic vulnerabilities in brain structure. These vulnerabilities cause people to behave or cope with their surroundings and emotions in a maladaptive way.
Although these vulnerabilities may be genetic in origin, they may be also be influenced by intrauterine development or experiences in early childhood. "We still lack specific knowledge about the nature of the individual vulnerabilities involved," said Siever.
According to Siever, people with BPD have a lower threshold for an emotional flare-up than others and tend to act out impulsively when they feel upset.
"People with BPD rely so much on others to help them deal with a stormy emotional pattern that they feel that their survival is threatened when the other person isn’t there," said Siever. He added that these maladaptive behaviors seek to re-regulate the person’s emotional state.
"If a relationship ends, for instance, someone with BPD may plunge into a number of promiscuous relationships, which serve to relieve the pain they feel over the lost relationship," he said.
Or they may cut or burn themselves when a therapist or a loved one leaves town to distract themselves from resulting feelings of dread or abandonment.
Some innovative research on BPD has focused on aggressive and impulsive behaviors and their relationship to serotonin, which may play a role in regulating systems in the brain that release aggression, according to Siever.
One way of studying the function of serotonin in the brain, said Siever, is to look at a breakdown product, or metabolite, of serotonin, 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid around the brain. "Concentrations of 5-HIAA have been found to be low in people with histories of aggression, which suggests that the possibility of low serotonin activity may be associated with more aggression," said Siever.
Emil Coccaro, M.D., and Richard Kavoussi, M.D., found in 1997 that fluoxetine reduced aggression scores in people with personality disorders. A year later, the researchers found that divalproex sodium is an effective treatment for impulsive or aggressive behavior in those with personality disorders who fail to respond to selective serotonin reuptake inhibitors such as fluoxetine.
In addition, Siever said that antipsychotic agents in low doses may help the most acute symptoms of BPD.
Medications, however, are only part of the picture. While medications can provide some symptom relief, psychotherapy can enable the unlearning of maladaptive therapies and increase compliance with medications, according to Siever.
One particularly successful mode of therapy used in people with BPD is dialectical behavioral therapy (DBT), a form of cognitive behavioral therapy pioneered by Marsha Linehan, Ph.D., a psychologist at the University of Washington at Seattle, in the 1980s.
DBT targets high-risk suicidal behaviors first, then behaviors that interfere with therapy, and finally, behaviors that interfere with quality of life. It "applies directive, problem-oriented techniques that are balanced with supportive techniques, such as reflection, empathy, and acceptance," Linehan said in an article reporting a study that compared outcomes of people with BPD who received DBT with those who did not.
The study, published in the December 1991 Archives of General Psychiatry, found that 62 percent of those who had not received DBT attempted suicide, while only 35 percent of those receiving DBT did.
Patients who received DBT had an average of nine inpatient hospital days per year compared with 39 days for those who had received no DBT.
Another study by Linehan in 1994 also found less suicidal behavior, less anger, and better self-reported social adjustment in people with BPD who received DBT.
Even with these positive outcomes, there is a lack of research on all phases of BPD. "BPD confronts us with a clinical dilemma," said Siever, who added that the disorder has not received the attention from the psychiatric research community that it deserves. ▪