Psychiatrist Otto Kernberg of New York’s Weill Cornell Medical College, one of the first researchers to describe the borderline personality, has long seen an overly rigid approach to life as a consistent feature. In his view, it evolves out of direct experience of physical or emotional abuse or witnessing others being abused, though he acknowledges the contribution of such biological defects as an overactive amygdala. He finds that borderline patients have a tendency to separate experiences into “positive” and “negative” buckets in their mind—a maneuver they engage in, he says, to prevent positive experiences from being contaminated by negative ones. A person may cling to sunny memories of his mother buying him an ice cream cone, for example, even though she abandoned him later on.
As they mature, borderlines continue to idealize some things and demonize others to make sense of a world that seems frightening. “There’s a lack of capacity for a realistic assessment,” says Kernberg. A friend who merited endless love on Monday could be persona non grata by Tuesday because she turned down an invitation to coffee.
Perhaps as part of an attempt to cope with abuse, borderline patients may have a distorted perception of time, says San Diego’s David Reiss. They see it more as an accumulation of distinct events than a continuous linear progression. It leads to difficulty in perceiving the chronological sequence of events. The misperception of time may compound the problems borderlines face in fulfilling life responsibilities.
Intractable No More
Perhaps the most remarkable aspect of borderline personality disorder is the view that has emerged over the past decade that, despite the array and depth of deficits, it is not an intractable condition. With treatment, symptoms like suicide attempts and cutting remit. “Most patients lose some symptoms rapidly,” observes McGill University psychiatrist Joel Paris.
The most specific and best-evaluated treatment for borderline personality disorder is dialectical behavior therapy. Developed by University of Washington psychologist Marsha Linehan, DBT grew out of her failed attempts to treat borderlines with traditional cognitivebehavior therapy. Patients perceived its emphasis on change as totally invalidating and often dropped out of therapy. The “dialectical” in DBT reflects the paradox at its heart—communicating radical acceptance in the face of constant self-invalidation while recognizing the need for change.
The therapy aims first to diminish suicidal behavior, then to impart such basic behavioral skills as emotion regulation and distress tolerance. “The ultimate goal of treatment,” Linehan has said, is “to move the client from a life in hell to one worth living, as quickly and efficiently as possible.”
Since the early 1990s, randomized trials have shown that, compared to treatment as usual, DBT diminishes attempts at suicide and self-harm and reduces psychiatric hospitalizations. Even a year after the end of treatment, patients also report less anger and depression.
If there is a problem with DBT, it is that it is not widely available. What’s more, it is costly and lengthy, says Paris. Only a small percentage of patients wind up getting DBT. “It needs to go from elite to accessible,” he says. Further, he questions whether it needs to last for a year. “There’s evidence that most of the changes occur in the first six months. Nevertheless, we’ve all been influenced by it. We’ve all become much more practical about treatment,” focusing on imparting behavioral and life skills.
Another psychotherapy specifically developed to treat borderline patients, mentalization therapy, draws more on psychodynamic principles. In both group and individual sessions, patients learn to recognize the emotional states of themselves and others and how they give rise to specific behaviors.
Still, holding a job is an achievement for borderlines. Recent studies show that even after symptoms like self-injury remit with therapy, as few as a third of sufferers are able to work full-time. Many hold part-time jobs or positions that are not self-supporting. “Once they are off their life trajectory,” observes the Mayo Clinic’s Palmer, “getting on a path is difficult.”
The real problem with treating borderline personality disorder, however, is that patients don’t get the right diagnosis. Many are misdiagnosed as having bipolar disorder and treated accordingly. “Lots of patients are on antipsychotics, mood stabilizers, and antidepressants,” says Paris. “They may be taking four or five drugs. They are not getting psychotherapy, and many insist on staying on pills. Borderline personality disorder is a condition in which psychotherapy is more effective than drugs. The evidence for drugs in the treatment of BPD is very weak.”
Debbie Corso says she “found the way out of hell” with DBT. “My journey proves that people can and do get better from this condition. There is definitely hope.” She is thrilled that she no longer meets the criteria for diagnosis—that she has moved, she says, “beyond the borderline.”