Borderline Personality Disorder - Case Study Example

Borderline Personality Disorder: Understanding a Complex Condition Introduction Borderline personality disorder is both a fascinating and oftendebilitating condition. Interest in this disorder has dramatically increased in comparison with other personality disorders (Linehan, 1993, p. 3). Mental health professional diagnose borderline personality disorder in 33% of outpatients and 63% of inpatients (Linehan, 1993, p. 3). Follow-up studies of patients with this disorder have shown that significant clinical improvement is slow. Often borderline patients must wait several years before they see improvement in their day-to-day lives (Linehan, 1993, p. 3). These results are alarming considering the fact that 70-75% of borderline patients have a history of at least one self-injurious act (Linehan, 1993, p. 3). In addition to this, borderline patient populations have a suicide rate of 9% (Linehan, 1993, p. 3). As the underlying framework of this personality disorder remains elusive, it has become increasingly misdiagnosed and mistreated. In this project, the researcher will analyze a case study of borderline personality disorder. The researcher will then apply both Ryle's cognitive analytic theory of reciprocal roles and a genetic model of personality disorders to this case in order to further investigate this disorder. Finally the researcher will show how an integrated model that combines elements from both perspectives is the most effective method in understanding this complex and largely misunderstood disorder. Case Study In their work, A Casebook in Abnormal Psychology, Halgin and Whitbourne (1998) investigated the case of Ann, a woman diagnosed with borderline personality disorder. In order to assess and formulate an effective treatment strategy, it was necessary to understand the context of experiences within Ann's life. She explained that one of her earliest memories was the belief that she had been an unwanted child. She held the belief that her parents did not divorce in order to make her a 'legitimate' child (Halgin & Whitbourne, 1998, p. 11). She explained her childhood environment as a "living hell" (Halgin & Whitbourne, 1998, p. 11). Ann's mother showed her significant attention and care during the first two years of her life. Ann explained the close relationship with her mother as a method that would protect them both from her father. Both her mother and father constantly argued with each other and Ann attributed herself as the inherent cause of this conflict (Halgin & Whitborne, 1998, p. 11). The close relationship that both her mother and she shared was downgraded with the birth of her younger sister when Ann was two years old. As her mother focused the majority of her attention on her sister, Ann felt both lonely and vulnerable (Halgin & Whitborne, 1998, p. 11). During the following years of Ann's childhood, she focused her efforts in order to regain the love and affection from her mother that had been lost with the new addition of the family. While her efforts worked occasionally, she would often receive criticism and frustration from her mother (Halgin & Whitborne, 1998, p. 11). With the birth of her second sister, Ann's need of an intimate relationship with her mother was more pronounced than ever before. Though Ann continued to seek approval and love, she explained that her mother began to take a firmer stance of criticism towards her. Both her mother and father now explicitly named her as the cause of the difficulty and misery within the family (Halgin & Whitborne, 1998, p. 11). During adolescence, Ann became anorexic. Shortly after Ann's condition became apparent, her mother began to disprove of her behaviour. Within a year, Ann began to gain weight and returned to relatively normal behaviour (Halgin & Whitborne, 1998, p. 12). Ann held deep resentments toward her sisters but refrained from expressing these feelings most of the time. Occasionally she would criticize or physically attack her sisters during periods of time when she felt particularly stressed or upset. Ann would subsequently feel significant guilt and regret due to her actions and would then display nurturing and loving behaviour toward her sisters thereafter (Halgin & Whitborne, 1998, p. 12). Ann explained that the relationship she had with her sisters mirrored the relationship that her mother had with her. This behavioural pattern was the prototype that later characterized the majority of Ann's intimate relationships (Halgin & Whitborne, 1998, p. 12). Ryle's cognitive analytic theory Ryle's cognitive analytic theory of reciprocal roles analyzes the self in terms of relationships or discourse with internalized characters and voices (Howell, 2005, p. 121). Ryle posited that the basic components of the self are enduring patterns of interactions that are predicated upon the early role relationships with family members (Howell, 2005, p. 121). Ryles' cognitive analytic therapy, known as CAT, focuses on both the embedded nature of the person within their social environment and the significance of the internalization of reciprocal role relationships within a person's personality development (Howell, 2005, p. 122). The fundamental units of description within Ryles' therapy model are the reciprocal role procedures, known as RRPs. These are relational units that include generalized procedural memories (Howell, 2005, p. 124). Ryle argues that RRPs manage and regulate how an individual thinks and behaves. In addition to this, RRPs formulate the content and extent of an individual's expectations of others (Howell, 2005, p. 122). Ryle explains that RRPs function both internally and interpersonally and that this interplay establishes a general understanding of reality within the self. Ryle posits that the self is dependent on others and ultimately embodies the actions and reactions of the individual. The interdependence of the self towards others progresses throughout life. Thus an individual's significant interactions with intimate relationships result in the embodiment of associated meanings and emotional reactions that may not be discernable solely with verbal language (Howell, 2005, p. 124). Ryle posits that an individual internalizes relational processes. This aspect of Ryle's cognitive analytic theory contrasts other psychological theories that describe objects and object relations as being the internalized constituents of the self (Howell, 2005, p. 124). Ryle describes his theory as a semiotic object relations model and argues that before children develop formal language, they associate meanings and intentions with body language, movement, and voice tone (Howell, 2005, p. 123). In other words, learning and personality development take place within the context of interpersonal relationships. The various meanings within one's reality are established with the development of their intimate relationships (Howell, 2005, p. 123). According to Ryle, the self is formed from interpersonal dialogue and he highlights the fact that the self is dependent on others for both consciousness and thought processes (Howell, 2005, p. 123). Ryle recognizes borderline personality disorder and many aspects of psychosis to be associated with dissociative states of the self. He describes borderline personality disorder as a limited range of roles that include extreme affects and states of partial dissociation (Howell, 2005, p. 125). States of partial dissociation include impaired memory though it is rare for an individual to exhibit complete amnesia as they maintain a degree of self-awareness most of the time (Howell, 2005, p. 125). Patients with borderline personality disorder have alternating dominance of a narrow range of reciprocal role patterns (Howell, 2005, p. 125). Ryle's theory of reciprocal role patterns puts forward that dissociation may occur as a consequence of disconnections between the self and family members with aggressive or helpless relational patterns. While healthy development is predicated upon the internalization of positive reciprocal role interactions, maladaptive behavioural patterns are often derived from neglect and abusive circumstances of the individual that results in a significant lack of an integrated, adaptive, and flexible sense of identity (Howell, 2005, p. 125). In the aforementioned case study, Ann grew up internalizing dysfunctional role relationships. This process resulted in a form of pathological dissociation that led to her diagnosis of borderline personality disorder. Ann was both neglected and emotionally abused as a child that led to an inadequate assistance in naming experiences and in associating them within the context of interpersonal events (Howell, 2005, p. 125). In addition to this, the trauma that Ann experienced resulted in her dissociating aspects of her overwhelming environment by fragmenting aspects of herself (Howell, 2005, p. 125). Within this case study, Ann frequently alternated confusing states of reciprocal roles. These changes of reciprocal role patterns involved both response shifts and role reversals within equivalent self-states (Howell, 2005, p. 125). Ann seemed to have internalized the dynamics of her early relationship with her mother that was characterized by neglect and emotional abuse. Later in life she projected reciprocal roles onto her sisters. In this case she assumed the role of the abuser and she projected this onto her sisters that held the role of victim. As in her early relationship with her mother, there was a period following abusive outbursts where Ann would seek to console and comfort her sisters. A genetic model of personality disorders Both brain activity and neural structures have biological origins and modern research has shown that these factors play a significant impact on the development of borderline personality disorder. All psychodynamic models regarding the assessment and understanding of borderline personality disorder have been challenged by modern empirical research literature (Gabbard, 2005, p. 435). Three main conclusions may be surmised from this empirical research. First, borderline patients generally regard their maternal relationship as inadequate or distant. Second, the father's absence is a more discriminating aspect within the family than the maternal relationship. Third, unlike many of the psychodynamic models, genetic and biological factors may play a significant role in the development of borderline personality disorder in addition to the maternal and paternal relationships (Gabbard, 2005, p. 435). While many factors that contribute to the development of borderline personality disorder appear to be trauma related, there are many aspects that may be due to genetic influences (Gabbard, 2005, p. 442). There are a significant number of borderline patients that do not report histories of trauma or violence. Thus, in addition to psychodynamic influences, other factors must be considered when understanding borderline personality disorder. Genetic studies were conducted for this disorder from which monozygotic twins showed a concordance rate of 35% while dizygotic twins showed a concordance rate of 7% (Gabbard, 2005, p. 442). The fact that borderline patients are heterogeneous suggests that this disorder is influenced by a number of genetic dimensions that may produce a diverse range of phenotypes (Gabbard, 2005, p. 442). The psychobiological model of personality contains four components of temperament and three dimensions of character (Gabbard, 2005, p. 442). According to this model, 50% of personality may be attributed to temperament (Gabbard, 2005, p. 442). Temperament is derived from genetic factors and thus the genetic role is important in understanding this complex disorder. The four features that characterize the concept of temperament include the following. The first characteristic is novelty seeking in which an individual often displays exploratory behaviour in response to novel circumstances, impulsive decision-making, exaggerated actions and reactions, unstable emotional states, and an aversion towards frustration (Gabbard, 2005, p. 442). The second aspect is harm avoidance in which an individual harbours a pessimistic concern for the future. Often one will display avoidant behaviour that is composed of a general fear of ambiguity, social anxiety and periods of exhaustion that occur with rapid onset (Gabbard, 2005, p. 442). The third component is reward dependence in which an individual may be characterized by sentimentality, interpersonal dependence, and the need for external validation (Gabbard, 2005, p. 442). The final dimension of temperament is persistence in which an individual is characterized by their capacity for diligence despite feelings of frustration and fatigue (Gabbard, 2005, pg. 442). The three features that describe the concept of character are derived from interpersonal interaction, intra-psychic fantasy, and traumatic experiences (Gabbard, 2005, p. 442). The first feature is self-directedness in which an individual takes responsibility for their decisions instead of blaming others, accepts themselves, and identifies life goals (Gabbard, 2005, p. 442). The second aspect is cooperativeness in which an individual shows varying levels of empathy, compassion, and social acceptance (Gabbard, 2005, p. 442). The final aspect of character is self-transcendence in which an individual accepts and identifies pursuits that are beyond the self (Gabbard, 2005, p. 442). Both temperament and character dimensions of an individual are important to assess and understand when diagnosing borderline personality disorder (Gabbard, 2005, p. 443). Low levels of both self-directedness and cooperativeness are fundamental attributes in patients with this disorder. In addition to this, borderline patients display high levels of both novelty seeking and harm avoidance behaviour (Gabbard, 2005, p. 443). Borderline personality disorder seems to have paradoxical elements as patients harbour deeply conflicting motivations. A genetic-biological diathesis model would explain the conflicting aspects of borderline personality disorder. The effects of traumatic experiences interact with the underlying predisposition of this disorder (Gabbard, 2005, p. 443). Thus, in the aforementioned case study, Ann possessed aspects of both temperament and character that led to her development of borderline personality disorder. Ann would diligently pursue the love of her mother by finding novel methods of winning her affection. In addition to this, Ann seemed to have accepted responsibility for her inability to successfully create her desired intimate relationship with her mother. She subsequently internalized these failed attempts by interpreting her mother's rejection as a reflection of Ann's flawed self. Later, though Ann would often harbour an uncooperative stance toward her sisters, she would subsequently make great efforts to comfort and care for them following outbursts of conflict. Evaluation Ryle developed the CAT method in order to integrate both the cognitive and psychoanalytic perspectives when treating mental disorders (Bateman, Brown, & Pedder, 2003, p. 171). Ryle's theory includes a cognitive dimension, as certain elements are intellectual in nature. Using Ryles' approach, the borderline patient understands that self-awareness and conscious choice are essential aspects toward change (Bateman, Brown, & Pedder, 2003, p. 171). CAT contains an analytic dimension as well in that it focuses on internal object relations that are derived both from early experiences and modified in fantasy. These elements are then understood to influence present relationships (Bateman, Brown, & Pedder, 2003, p. 171). Both transference and counter transference guide therapy and there is an emphasis on relationships in addition to cognitions (Bateman, Brown, & Pedder, 2003, p. 171). The central deficiency of Ryle's approach is that it does not include genetic or biological factors that effect and contribute to borderline personality disorder. In their study, Figueroa and Silk (1997) found that borderline patients have significantly lower levels of serotonin activity in the brain when compared to individuals that do not have this disorder. Serotonin has inhibitory effects on behaviour and the impulsive and unstable mood states of borderline patients may be attributed to these altered levels of serotonergic activity (Figueroa & Silk, 1997). In addition to the previous study, neuro-imaging studies have shown that borderline patients have lower volumes of both hippocampal and amygdalar regions when compared to individuals without this disorder (Gabbard, 2005, p. 440). The decrease in hippocampal volume may help to explain difficulties that borderline patients have in determining how current relationships mirror past relationships and how present experiences are related to past circumstances (Gabbard, 2005, p. 440). In addition to this, volumes of both frontal and orbitofrontal lobe regions were also reduced in borderline patients (Gabbard, 2005, p. 440). Decreased functioning of prefrontal inhibitory regions may contribute to increased hyperactivity in the amygdala (Gabbard, 2005, p. 440). This may explain the anxious and avoidant behaviour found in borderline patients. In their study, Zanarini and Frankenburg (1997) posited that there are three main factors when assessing and understanding the etiology of borderline personality disorder. The first cause arises from traumatic experiences that include early separations, abuse, and neglect from primary caretakers. The second factor is a biologically derived vulnerable temperament (Zanarini & Frankenburg, 1997). The final element is associated with triggering events in which a certain experience or set of experiences may act as a catalyst that produces the symptoms of borderline personality disorder (Zanarini & Frankenburg, 1997). An example of this occurs when an individual attempts and fails to establish an intimate relationship with a primary caregiver. In his study, Paris (1998) argued that certain kinds of genetically derived temperaments might increase the possibility that negative experiences or circumstances arise in an individual's life and therefore there is a continuous interaction between their gene's and their environment in the development of borderline personality disorder. These studies suggest that a multifaceted approach is necessary to both understand and treat borderline personality disorder. Combined treatments of medication and psychotherapy for borderline patients have become the standard strategy for most cases (Gabbard, 2005, p. 444). Within the aforementioned case study, Ann actively hindered her own progress toward conflict resolution and goal attainment with both her mother and her sisters as she harboured the maladaptive attitude of ambivalence (Halgin & Whitbourne, 1998, p. 14). As a result of this, she would often undo the progress that she had made regarding her maladaptive behaviour patterns. Ann would often retract her kind words and gestures with criticisms and attacks toward her loved ones. Her ambivalence often prevented her from progressing toward her goals (Halgin & Whitbourne, 1998, p. 14). Ultimately, several factors contributed toward Ann's development of borderline personality disorder. Her traumatic environment with her mother and father had a significant impact on her. The nature of her relationship with her mother influenced Ann's later relationships with her younger sisters. Ann also displayed a vulnerable temperament that was characterized by a pessimistic attitude towards the world with her general ambivalence toward intimate relationships. While this attitude was counterproductive towards her efforts, she continued to dedicate a significant amount of time and energy toward the reward behaviour of creating close connections with her family and friends. Finally, the catalyzing event in Ann's life was the birth of her first sister when Ann was two years old. This event had a significant impact on the nature of Ann's relationship with her mother. It was the transformation of this relationship that led Ann to cultivate her ambivalence and diligence toward restoring the once loving relationship that she had with her mother. This case study exemplifies both the genetic and psychodynamic factors that contributed toward Ann's development of borderline personality disorder. References: Figueroa, E., & Silk, K. (1997). Biological implications of childhood sexual abuse in borderline personality disorder. Journal of Personality Disorders, 11 (1), 71-92. Gabbard, G. (2005). Psychodynamic psychiatry in clinical practice. Arlington: American Psychiatric Publishing, Inc. Halgin, R., & Whitbourne, S. (1998). A casebook in abnormal psychology. New York: Oxford University Press. Howell, E. (2005). The dissociative mind. Hillsdale: The Analytic Press. Linehan, M. (1993). Cognitive-behavioural treatment of borderline personality disorder. New York: Guilford Press. Paris, J. (1998). Chronic suicidality among patients with borderline personality disorder. Psychiatric Services. Zanarini, M., & Frankenburg, F. (1997). Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 11 (11), 93-104. Read More