Consult-Liaison Education Medicine

Personality Disorders (VII): Where Does the Borderline Variety Come From?

Though I finished my last post with questions about treatment for antisocial personality disorder, I am going to change course and instead discuss the other two personality disorders for my talk first. (I ultimately cannot discuss specific treatments for each condition, partly because some of the conditions unfortunately do not have evidence-based treatments, but also because some of the treatments overlap.)

Much of the literature discusses the treatment of borderline personality disorder, though few discuss etiologies of this condition. As with antisocial personality disorder, there is evidence that children who experience abuse or neglect are at higher risk of developing borderline personality disorder. There are more ideas than evidence about the development of this condition.

There are two major hypotheses (one from the behavioral school of thought, the other from the psychodynamic school) about the etiology of borderline personality disorder.

Marsha Linehan, who developed dialectical behavior therapy, argues that borderline personality disorder develops as a consequence of two factors. The first is biological: Some individuals are just genetically programmed to experience more emotional sensitivity—meaning more intense emotions that last a longer period of time—than the “average” person. Impulse control (now considered a heritable trait) is often a challenge for these individuals as well.

The second factor is environmental: Individuals with borderline personality disorder often grow up in invalidating environments. These two factors combined can result in children never learning the skills to regulate their own emotions.

When I am teaching these concepts in person, I usually draw a graph that shows the hypothesized difference between how the “average” (whatever that even means) person experiences an emotional response and how someone with borderline personality disorder experiences an emotional response. The point is to see that people with borderline personality disorder are often overwhelmed by emotions, which can result in impulsive behavior.

All human beings, when overwhelmed, can behave in ways that are impulsive. Think about the last time you were really stressed out. Maybe you spoke too soon, did something you now regret, or didn’t behave the way you and others expect you to behave.

Now imagine having those experiences throughout the day.

When I describe invalidation, I usually share the example of “Little Suzie” who draws a picture of a horse. She is pleased with her drawing and shows it to her parents. She expects that they will feel pleasure from this drawing, too.

They don’t recognize it’s a horse.

“It doesn’t even look like an animal,” they comment. “Why are you proud of this?”

Little Suzie naturally begins to cry because she was proud of her drawing. Upon seeing this, her parents reply, “Why are you crying? You’re too sensitive. There is nothing to be sad about. Stop being silly and stop crying.”

As this happens repeatedly to Little Suzie she learns that her internal experiences are “wrong”. The messages she receives from the external world consistently contradict the messages she receives from her internal world. Thus, she learns to distrust or disbelieve her internal experiences.

There are rare moments, though, when the world seems to “agree” with her internal experiences when she engages in certain behaviors (like cutting her skin; suddenly, people tell Suzie things like, “Wow—you must be feeling really bad if you cut your wrist like that!”). She thus learns that the one way she can receive emotional validation is when she demonstrates behaviors like trying to kill herself.

Both the behavioral and psychodynamic formulations (see below) comment that sexual abuse is a risk factor for the development of borderline personality disorder. You can imagine that sexual abuse is a highly invalidating event (“I know this feels good to you, too… but don’t tell anybody…”).

Psychodynamic formulations (Otto Kernberg focused on this condition) argue that borderline personality disorder originates when toddlers become alarmed about the potential of their mothers disappearing. He argued that these individuals are “repeatedly reliving an early infantile crisis in which they fear that attempts to separate from their mother will result in her disappearance and abandonment of them”.[1. From Gabbard’s Psychodynamic Psychiatry in Clinical Practice, page 434.] Kernberg has also argued that these individuals have problems integrating stable, constant ideas/constructions about people (and themselves) in their own minds, which results in these individuals believing that people are either all good or all bad, rather than a mixture of the two.

Bateman and Fonagy have argued that borderline personality disorder comes about because these individuals “have a great deal of difficulty appreciating and recognizing that perceived states of oneself and others are fallible and subjective and are representations of reality that reflect only one of a range of possible perspectives”.[2. From Gabbard’s Psychodynamic Psychiatry in Clinical Practice, page 436.] This is similar to the view above about people being either all good or all bad. It is difficult to consider different viewpoints when you’re experiencing an intense emotion.

And… that’s really about it in terms of how borderline personality disorder comes about. People with borderline personality disorder often die from self-injury (whether inadvertently or not) and, unfortunately, many people assume that these individuals don’t need or want help. It is unfortunate that we don’t know enough about this condition to help prevent it from occurring, but at least we know information to help treat it when it presents.

We’ll go over DSM-4 diagnostic criteria next.