MHM Magazine

42 | MENTALHEALTHMATTERS | Issue 4 | 2021 MHM health disorders, the cause of BPD was “a combination of nature and nurture”. “There are strong hereditary factors in the causes of most personality disorders. In terms of nurture, the individual’s early childhood environment, the form of parenting experienced, and their early childhood development all play a significant causative role. A lot of emphasis also falls on the person’s attachment style, based on the nature of their childhood bond or connection with their primary caregiver. “We commonly see a real or perceived sense of abandonment or rejection triggered, for example, by the death of a parent or a divorce during the person’s early childhood, which leads to the pervasive feelings of rejection or abandonment experienced in borderline personality disorder,” she said. “For people with borderline personality disorder, the fear of abandonment is deep-seated and chronic, and they will respond with intense emotion and behaviour to real or perceived rejection”, she said. Dr Moodley added that it was important to distinguish between the feelings of rejection that many people experience occasionally, and the BPD patient’s “constant stream of thoughts of being rejected and abandoned” in response to everyday events. “The BPD patient’s response is not like a once-off reaction which could be explained or contextualised by a person being under more stress than usual, for example. This is a deep fear, a regular, frequent pattern of interpreting some small incident – such as a partner being a few minutes late for a date – as utter abandonment, resulting in accusations and angry outbursts that are disproportionate to the situation. “The person with BPD may threaten to block the other person or end the relationship, and in extreme cases make threats to self-harm or commit suicide. “Meanwhile, the other person is often left completely befuddled because the reaction is out of all proportion. This is one of the aspects that make it difficult to live with someone who has BPD,” explains Dr Moodley. She said feelings of rejection for individuals with BPD were a daily, if not hourly, occurrence. “It’s constant and it’s disruptive emotionally, socially and in their work lives. They feel a constant, intense psychological sense of being emotionally tortured.” The other core characteristics of BPD are instability in moods and emotions. The person with BPD is unable to regulate their thoughts and feelings, and many describe a sense of emptiness, hollowness or numbness. They also display impulsive and reckless behaviour such as impulsive eating or abuse of alcohol and/ or drugs, reckless driving, impulse buying, out-of-control gambling or impulsive, disinhibited sexual behaviour. Dr Moodley said this impulsive behaviour may be seen as an attempt to “fill the hole”, and similarly their tendency to latch onto one person and form co-dependent relationships may also be a strategy to soothe the emptiness or numbness. People with BPD tend to struggle with their sense of identity and sense of where they fit in in the world, expressing these “chronic internal battles” in frequent and often dramatic external changes, she said. “This is often an insatiable desire – they’re not satisfied with just one tattoo or a hair colour change, for example. However, it’s important all factors are taken into account before making a diagnosis – just because a person changes their hairstyle doesn’t by itself indicate a personality disorder,” she said. Dr Moodley said people with BPD tended to have “rollercoaster relationships” – highly intense and extremely unstable personal, family and work relationships. “They move from euphoric highs of idolising the other person, describing them as the ‘best friend ever’ or the ‘dream partner’ but within hours or days, their mood may rapidly plummet to extreme lows where the other person is now the ‘worst friend ever’, the new partner is ‘the absolute pits’.” People with BPD display “an exquisite sensitivity” in interactions with other people, she said, coming across as thin-skinned and hypersensitive to any perceived slight. At times, their response to interpersonal conflict can appear to be paranoid. “A comment which others might disregard, may be latched on and fixated on by the BPD patient, eventually snowballing into an intense emotional response or angry outburst,” Dr Moodley said. Unlike other personality disorders, such as narcissism, individuals with BPD do feel intense remorse, guilt and shame, deepening their fear that their behaviour will lead to further rejection or abandonment. Dr Moodley said it was important that a medical diagnosis of BPD – or any other personality disorder – be made by a professional such as a psychiatrist or clinical psychologist, as several different conditions could have similar outward symptoms but different causes, requiring different treatment strategies. People with borderline personality disorder often have co-morbid conditions such as depression, anxiety, substance abuse or an eating disorder, and it’s therefore important to have a professional and precise diagnosis and tailored treatment programme. Patterns of self-harm such as cutting or burning and the high risk of suicide are of deep concern to the person with BPD and their loved ones. “The individual is unable to regulate their emotions, they don’t have the skills, and they struggle to identify their emotions accurately. They often describe very intense, deep emotional pain, a feeling of a tortured mind. These acts of self-harm are at times an attempt to substitute physical pain for the deeper inner pain, to distract the mind from the storm of emotions,” she said. Another theory is that self- harming and suicidal threats or behaviour may stem from the fear of abandonment or as a desperate attempt to control a situation in order to avoid being abandoned. Dr Moodley said treatment for borderline personality disorder was “a long road to walk”. Long-term medication is likely to be part of a plan tailored to the individual’s specific needs, and the mainstay would be psychotherapy or “talk therapy”, which has the strongest evidence base of effectiveness. She said dialectical behaviour therapy (DBT), one of the most strongly evidence-based therapies