Category: Education

If you haven’t read the proposed etiologies of borderline personality disorder first, please do so. An understanding of its causes makes the criteria seem less… judgmental and harsh.

Following is the definition of borderline personality disorder according to DSM-4.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

The authors here focus on instability, not only when interacting with others, but also with oneself and one’s emotions.

(1) frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

The vast majority of people don’t want to experience abandonment. “Frantic”, given the context, is open to interpretation. Upon reading this, you may think of multiple, desperate phone calls filled with promises that cannot be kept. These efforts, however, can also refer to someone who abruptly stays in bed and doesn’t acknowledge any communications from the outside world. “Frantic efforts” are not required to be loud.

(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

“Alternating between extremes of idealization and devaluation” is often described as something like this:

January 15: “I love my doctor—she’s the best doctor I’ve ever had. She is smart and really understands what I’m talking about. Don’t see anyone else in that clinic; no one else there is as good as she is.”

February 1: “My doctor is terrible. She thinks she’s really good, but she’s not. I’m not sure why they let her graduate from medical school—she doesn’t know what she’s doing and her bedside manner is crap. I would not recommend her to my worst enemy.”

Recall the concept of “all good/all bad”.[1. This “all good/all bad” concept comes from object relations theory. Object relations is not my forte; I’m much too concrete.] That is reflected here.

(3) identity disturbance: markedly and persistently unstable self-image or sense of self

Recall the experiences of invalidation children may experience while growing up. If you are regularly told that your thoughts, emotions, and behaviors are “wrong”, you, too, might have doubts about who you are, what you feel, and what you do.

(4) impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

This might speak to heightened “emotional sensitivity” (more intense emotions that last a longer period of time), which is considered a biological cause of this condition.

People also often confuse these behaviors with the hypo/mania described in bipolar disorder.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

This criterion was already mentioned twice before we got here! This is why some people use the mental shortcut of, “Well, she’s always trying to kill herself, so she must be borderline”.[2. Try this exercise if you work in health care: Describe your patients as people instead of medical conditions. No, he’s not “the liver cancer in bed seven”, he’s “Mr. Smith, the man diagnosed with liver cancer”. Yes, emotional distance can be useful, but if you habitually think of your patients as diagnoses, that might lead you to treat your patients as if they weren’t people.] Like many shortcuts, this can lead you to the wrong conclusion.

Remember that Little Suzie learned that people seemed to only really understand her internal distress when she did things like injure herself. This is the best way she knows how to get her emotional needs met. This is a skills deficit. (To be clear, you could say that “she’s manipulative”, but we all manipulate each other all the time. I’m arguably manipulating you right now with these words. We often use the word “manipulative” when the manipulation isn’t skillful. People would do something different if they could in that moment.)

(6) affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

This again refers to the “emotional sensitivity” discussed above in criterion 4. People also confuse this with mood fluctuations seen in bipolar disorder.

(7) chronic feelings of emptiness

This can be related to the “identity disturbance” described in criterion 3 above.

(8) inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

(I encourage all to use the word “inappropriate” with caution. What is “inappropriate” strongly depends on the context.)

This, too, refers to “emotion sensitivity” and the impulsivity that may result from it.

(9) transient, stress-related paranoid ideation or severe dissociative symptoms

This criterion explains the psychotic symptoms that can accompany borderline personality disorder. Some will recall the the name “borderline” came about because some theorists argued that these individuals are on the “borderline” between neurosis and psychosis.

Dissociation can be a skillful way of coping with stress. An extreme example is someone dissociating while getting raped. A more common example is someone dissociating a bit while at the dentist. Dissociation becomes a problem when it affects function (like dissociating while at a job interview).

Again, recall that a personality disorder is an “enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment”. People who work in health care settings often start using the word “borderline” to describe someone who they feel annoyed and frustrated with. That’s unfair. Words matter.

Next up is dependent personality disorder… for which there is sparse data.

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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.

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Now that we know how the DSM defines antisocial personality disorder, let’s see what the literature[1. Unfortunately, there isn’t a lot of data for many psychiatric conditions and phenomena. This frustrates clinicians and patients alike.] says about its causes.

One paper that argues that children whose mothers are experiencing depression are more likely to demonstrate antisocial behaviors. This is a “nurture” proposal, as mothers experiencing depression may not have more difficulties with the role of parenting. This can result in more stress for the family.[2. This, along with many of the other studies discussed here, harkens back to the “schizophrenogenic mother“, which is controversial.]

The authors also argue that genetics accounts for about one-third of the association between mother and child antisocial behaviors. This is the “nature” proposal, as the data suggests that treating depression in mothers alone does not prevent the development of antisocial behaviors.

Do note that the study looked at kids at ages five and seven. We have no idea how many of these kids ultimately demonstrate symptoms consistent with conduct disorder. Recall that a diagnosis of conduct disorder (by age 15) must precede a diagnosis of antisocial personality disorder (earliest at age 18).

Here’s a paper that discusses childhood spanking and a possible relationship with antisocial behavior. (Again, this paper does not comment on the the development of conduct disorder.) The authors interviewed parents and asked them if they spanked their children in the past week. According to the paper, the more parents spanked their children, the more likely the children were to develop antisocial behaviors. The authors conclude, “When parents use corporal punishment to reduce [antisocial behaviors], the long-term effect tends to be the opposite.”

It’s not clear if the interview also screened for other events occurring in the home, including substance use, violence between the parents/caregivers, education, etc.

There’s evidence that children who “experienced substantiated child abuse and/or neglect from 1967 to 1971 in a Midwestern metropolitan county area” were, as adults, significantly more likely to demonstrate symptoms of antisocial personality disorder. These diagnoses came from a two-hour interview… which, again, generally isn’t how personality disorders are diagnosed in clinical practice. (Rarely do psychiatrists get two hours with clients and, as previously noted, personality disorders are usually diagnosed after working with a client over time.)

Here’s an argument that male children born to women with severe nutritional deficiency were more likely to develop antisocial personality disorder. The authors concluded that the risk was highest if the mother experienced “nutritional deficiency” (famine) during the first and second trimesters.

During famine and war, there are numerous relevant factors that may affect this: People can get really ill (dysentery, tuberculosis, etc.). People experience both physiological and psychological stress during these times. It may not be nutritional deficiency alone that results in antisocial personality disorder. (Furthermore, the results of this paper would suggest that populations in North Korea and Somalia should have a higher incidence of antisocial personality disorder, which does not appear to be the case.)

So, hopefully, we now have more empathy for individuals with antisocial traits or personality disorder. They often had crappy things happen to them while they were growing up. As a result of their personal histories, could they have developed ways of coping that may have worked well in the past, but don’t work so well now (and may instead be construed as antisociety)?

Next: What can we do about this? How can we help these individuals?

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In casual parlance, the term “antisocial” can mean “shy” or “introverted”, as in, “No, I’m not going to that party… I’m feeling antisocial.”

The word “antisocial” in clinical settings, however, is an abbreviation for the condition of Antisocial Personality Disorder, which has nothing to do with shyness or introversion.

Here is how DSM-4 defines Antisocial Personality Disorder:

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

Think of “antisocial” as referring specifically to “antisociety”. (This is why people opine that Hannibal Lecter and Volde—uh, He-Who-Must-Not-Be-Named—have antisocial personality disorder. Do also note that the terms “psychopaths” and “sociopaths” refer to an extreme form of antisocial personality disorder, but not all individuals with this condition are violent serial killers. People who work in mental health often quip that there are some people with antisocial personality disorder who do quite well for themselves in government and CEO positions.)

We’ll talk more about the “occurring since age 15 years” part in criterion C below.

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

This criterion, when taken alone, is problematic. By definition, Galileo Galilei and Mahatma Gandhi would have been on their way to a diagnosis of antisocial personality disorder.

I repeat this often here, perhaps more so to remind myself: (1) Context matters, and (2) This is how psychiatry can become an agent of social control.

(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

This, paired with criterion A7 (“lack of remorse”), is often cited for this diagnosis.

(3) impulsivity or failure to plan ahead

This is a matter of degree. (We all, occasionally, are impulsive and don’t plan ahead.) The outcomes of the impulsivity and failure to plan ahead also matters. Generally, this criterion can result in the behaviors described in the rest of the diagnosis.

(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults

The modifier of “repeated physical fights or assaults” strongly suggests that this is not primarily an emotional condition; it is a behavioral condition. That “failure to conform to social norms with respect to lawful behaviors” refers to this.

(5) reckless disregard for safety of self or others

Individuals with this condition can be dangerous. They often die by violent means (such as suicide and homicide).

(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

Our culture values consistent work behavior and financial responsibility. This is why such behavior is considered “antisociety”.

(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

This is arguably the most compelling (and most often cited) criterion for antisocial personality disorder. Most people, regardless of which culture they belong to, feel some regret, shame, or guilt upon breaking a social contract. These individuals do not.

B. The individual is at least age 18 years.

A person must be a legal adult.

C. There is evidence of Conduct Disorder with onset before age 15 years.

By definition, Conduct Disorder is the predecessor of Antisocial Personality Disorder. DSM-4 defines Conduct Disorder as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific behaviors characteristic of Conduct Disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules.” The authors are arguing that Antisocial Personality Disorder doesn’t just come out of the blue. A pattern was already in motion.

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

This is a corollary to the previous criterion. Schizophrenia and a Manic Episode are considered “episodic” (yes, even schizophrenia). As you may recall, personality disorders are considered “chronic“.

You can now see why it can be challenging to work with people with antisocial personality disorder. To help us avoid automatic reactions of disdain for these individuals, we’ll next learn why people might develop this condition.