Family at the borderline

When Ellen’s* phone rang at one in the morning, her first thought wasn’t that it was a family emergency or other bad news. Her husband had the same idea: “don’t answer it,” he said groggily.

“She’ll just call back,” said Ellen, and picked up the phone. Sure enough, it was her sister, who had just broken up with the latest “perfect” match, and who was suicidal. Again. Recounting the story, Ellen seems in remarkably good spirits about it, “So I got in the car and drove over, in case I needed to take her to emergency. I’ve done it so often that I just think of it as a kind of fire drill.” But as she sips at her coffee, Ellen’s cool exterior slips a little. When I ask her if she isn’t worried about it, she admits, “I worry that one day she will follow through. I also worry that I’m so used to it, I won’t be able to tell the difference.”

Ellen’s sister Jane has been diagnosed with depression, bi-polar disorder, and most recently, the disorder that seems to be on many people’s tongues – borderline personality disorder, or BPD. When Ellen read up on the disorder, she says, “I kept turning to my husband and saying ‘this is it! This is exactly it!’”

What is BPD?
Borderline personality disorder (BPD) is characterized by what might in the past (and sometimes in the present) have been considered character defects: unstable, rapidly changing moods, difficulty in interpersonal relationships, poor self-image, and inconsistent behavior.

From the outside, people who suffer from BPD may look like “drama queens,” with frequent changes in jobs and long-term goals, and a string of bad relationships and poor relations with family and friends. They tend to either over-idealize others, singing their praises – at least until a small conflict occurs, at which point they go to the other extreme and vilify the individual in question. They react intensely even to small changes in plans or minor breaches of etiquette. Suicide threats and attempts may occur along with anger at any perceived abandonment or disappointments.

On the inside, people who suffer from BPD may view themselves as fundamentally bad, or unworthy. They suffer from cognitive distortion and may be genuinely unable to see others’ points of view, or to have a sense of proportion about events. They often feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are.

People with BPD may exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex.

This instability often wreaks havoc on family and work life, long-term planning, and the individual’s sense of self-identity. Originally thought to be at the “borderline” of psychosis, people with BPD are now understood to be suffering from a disorder of emotion regulation. Personality disorders in general “cause enduring patterns of inner experience and behaviour that deviate from the expectations of society, are pervasive, inflexible and stable over time, and lead to distress or impairment,” and affect about 8 to 9 per cent of the population, according to the Public Health Agency of Canada’s Report on Mental Illnesses in Canada.

It’s estimated that BPD affects 2 percent of adults. Patients diagnosed with BPD often need extensive mental health services.

Causes and treatment
Causes of BPD are not yet known, although many believe it develops through a combination of genetic and environmental factors, and many sufferers, although not all, report abuse and neglect in childhood. Ellen’s father was an alcoholic and she thinks this may have contributed to her sister’s disease, but wonders why she herself did not develop the disorder.

Neuroscientific research in the US is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. This supports the view that BPD truly is a disorder and not merely something that sufferers can “get over” on their own. This is an important finding as people who suffer from BPD continue to be perceived as “difficult people” rather than people who have a true disorder.

Group and individual psychotherapy are at least partially effective for many patients. Unfortunately the very characteristics of BPD can make it difficult for people with the disorder to stay in therapy, or listen to group experiences – to the extent that some professionals prefer not to work with patients with BPD at all. A new form of therapy, called dialectical behavior therapy (DBT), has been developed over the last 15 years and is considered the most likely technique to reach sufferers of BPD.

Psychiatric drugs can also be helpful in addressing specific concerns that patients have – antidepressants for depression, and anti-psychotics to help with cognitive distortion. But each case is highly individual.

“When she was going to therapy she did seem to be getting better,” Ellen says when I ask about her sister’s treatment, “But then she got into a relationship and stopped going. Maybe she’ll go back.”

Challenges for family
Ellen’s story about her sister demonstrates some of the difficulty that BPD sufferers and their families face. Suicide attempts and self-harm can become dangerous, and suicide is one of the most serious risks to the BPD sufferer, particularly if he or she becomes isolated from family and community.

At the same time, spouses, family members, and caregivers can all become burnt out while trying to relate to a person who suffers from BPD. They may feel as though they are walking on eggshells most of the time, trying not to provoke the considerable anger that may come their way if the person perceives a slight, or riding out impulsive behaviours. Whether through a formal network or informal support of friends and family, a person who cares for someone with BPD needs help in maintaining equilibrium.

“If it weren’t for my husband I think my sister would have driven me around the bend a long time ago,” says Ellen. “… he reminds me that she is who she is and not to get sucked into thinking that I’ve made a terrible mistake if I haven’t called in three days.”

“But still, I worry,” she says. “It’s stressful for me but I think it’s even harder for her.”

That’s the difficulty. If you suspect that you or someone you love suffers from BPD, it may be time to get a professional involved.