Explaining the connection
Personality refers to the enduring and habitual patterns of attitude, emotion, motivation, and ways of relating to others. Personality disorders may be understood as extreme version of general traits. For example, the attitude of a person with dependent personality who is confronting a new challenge might be: “If I don’t feel competent, I should seek someone to help.” With repetition, the belief becomes stronger. The biased belief (I’m weak) causes that person severe psychological distress.
Shahram Heshmat, Ph.D., is an associate professor emeritus at the University of Illinois at Springfield with a Ph.D. in Managerial Economics from Rensselaer Polytechnic Institute. He specializes in the Health Economics of addiction and obesity, applying the insights and findings that emerge from behavioral economics research to the decision processes underlying addictive behavior, obesity, and weight loss management.
Editor: Saad Shaheed
BPD is defined by instability of interpersonal relationships, self-image, affects, oversensitivity to social environment, and exaggerated impulsivity. About 1.1-2.5% of the general population display primary symptoms of BPD. Women BPD outnumber men by as much as 3 or 4 to one. The observed prevalence seem to decrease with age, many patients show substantial reduction in their symptoms. Many individuals with BDP are intelligent and gifted people, but their disorder prevents them from developing themselves (i.e., finishing education, or having jobs below their capacities).
How do borderline traits develop? The cause of BPD is complex. A combination of genetic and developmental (psychological roots) contributes to the development of the illness. BDP like normal personality traits are heritable which ranges from 40% to 50%. The relatives of patients with BPD have a 4-20 times higher prevalence of BPD compared to people in the general population. Context variables such as parenting behaviors are important factors. A number of studies link harsh treatment early in life (e.g., physical abuse and neglect) with later BPD. Alternatively, heritable traits of the child (e.g., a difficult temperament) may evoke adverse parenting styles that then further shape the child’s development in negative ways. However, not everyone with the disorder will have experienced childhood adversity. Most children who are traumatized never develop personality disorders. Genes are not destiny. Genes determines the extent to which we are sensitive to adverse environments.
Exposure to abusive, neglectful or unresponsive caregivers may result in a working model described by expectations that others will not respond to or meet one’s needs for love and care. This internal working model of the self guides all later relationships. He fears abandonment, so he clings. He fears too much closeness, so he pushes away. Too much closeness threatens him with suffocation. He ends up pushing away those with whom he most wants to connect. Because the internal working models function outside of awareness, they are change resistant.
The core feature of BPD is impulsivity and poor emotional regulation. Impulsive behaviors refer to acting on the spur of the moment in response to immediate environmental cues, without consideration of future consequences. Impulsivity manifests in potentially self-damaging activities that are rewarding in the short term, like anger outbursts, spending, substance abuse, eating and sex. The amount of impulsivity displayed by BPD patients can be extreme, and their inability to carry through plans causes sever harms to their lives (e.g., inability to hold down jobs and impoverished relationships).
Genetic factors and adverse childhood experiences (e.g., emotional neglect and abuse) might weaken capacity controlling impulse and making judicious decisions. For instance, neuroimaging studies show that borderline patients express hyperactivity in the part of the brain associated with emotionality and impulsivity (limbic areas), and decreased activity in the section that controls rational thought and regulation of emotion (the prefrontal cortex).
The dysfunction of self-regulation is particularly apparent in the context of social and interpersonal relationships. The emotional shifts or angry outbursts are often triggered by interpersonal events such as rejection or the fear of abandonment. BPD patients place a high priority on relationships. So anything that signals a threat to the relationship becomes a threat to their sense of self. Such behaviors make relationships with BDP patients very challenging for others. Family members often talk about “walking on eggshells” to avoid an emotion storm. The intensity of these emotions, such as angry outburst, makes them more difficult to control.
The intolerance of painful emotions leads them to denial (avoid feeling and thoughts), or self-medication. The efforts to avoid these experiences can manifest in impulsive and/or compulsive reliance on pleasurable activities such as eating, sex, buying, and using drugs and alcohol. These behaviors are a means to self-medicate fluctuating moods, and avoid negative feelings of emptiness and abandonment. Numerous studies have linked BPD with eating disorders and drug addiction. For example, 50% of all patients with eating disorders have uncovered BPD, and over 50 percent of substance abusers also fulfill criteria for BPD. Drugs dependency may be a substitute for nurturing social relationships, or a way to establish some sense of belonging.
Primary targets of treatments are inadequate emotional reactions, notably the poorly controlled expression of impulses and self-damaging behavior. The task of therapy is to help patients in acquiring skills in emotion tolerance without acting out behaviors that serve to avoid or escape from the experience, and understanding their emotions.