6. CultureAgeGenderFamily-DiffDX - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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Therapist Resources > Therapy Books > Ouch Borderline in Couples

Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy

The pattern of behavior seen in borderline personality disorder has been identified in many settings around the world.  Adolescents and young adults with identity problems (especially when accompanied by substance abuse) may transiently display behaviors that misleadingly give the impression of borderline personality disorder.  Such situations are characterized by emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers.  Borderline personality disorder is about five times more common among first-degree biological relatives of those with the disorder than in the general population. There is also an increased familial risk for substance-related disorders, antisocial personality disorder, and mood disorders.  The prevalence of borderline personality disorder is estimated to be about 2% of the general population, about 10% among individuals seen in outpatient mental health clinics, and about 20% among psychiatric inpatients.

There is considerable variability in the course of borderline personality disorder.  The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources.  The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age.  During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning (American Psychiatric Association, 1994).  There may be other considerations that correlate or may influence or cause borderline personality disorder, including biological considerations beyond family systems theories.  "...the borderline patient... often has a genuine deficit that sets off a chain reaction of unhelpful responses between family members.  Biologically based deficits can directly cause a lack of impulse control, poor frustration tolerance, intense affective needs, irritability, emotional explosiveness, and other psychological and behavioral manifestations.  Family conflicts, tensions, recriminations and a repertoire of behaviors developed to cope with such manifestations in the identified patient are often view mistakenly as pathogenic rather than responsive" (Johnson, 1991, page 171).

The individual or the partner may question why other family members are not likewise affected or respond in the same manner.  Family environment, parental care giving, birth order, and gender cultural standards are but a few of the influences on how innate temperamental traits are addressed for any individual.  The match and mismatch among multiple factors create varied outcomes.  Research expresses probability and percentages- often reflecting correlation as opposed to causation.  "…therapeutic methods that start with educating the family and the symptomatic individual about possible biological, interpersonal, and environmental contributors remove the blame and convey the therapist's conviction that families want to help and are competent to do so, given appropriate information and guidance (Anderson, 1983); Schulz et al., 1985)" (Johnson, 1991, page 171).  In couple therapy, the therapist needs to gain acceptance that the family-of-origin had functioned as well as it could.  Furthermore, also gain acceptance of current couple or family functioning.  Such acceptance acknowledges limitations, and best intentions, as well as problematic outcomes.

The therapist may want to "identify which of three patterns or combinations of patterns families are using to cope: denial, intrusiveness and overcontrol, or the sacrifice of their own lives and concentration entirely on the ill family member (page 172).  From understanding how the individual and the relationship patterns have come to be, there will ensue logic of how to grow and change.  The therapist's interest in and attention to the individual and collective stories conveys acceptance of their experience and reality.  Active listening meets both members' needs to be heard.  Each person needs to tell his or her story of the issues or disorder, his or her life, previous families and relationships, and the course of the relationship... and feel heard.  Each person needs to learn about what the therapist considers to be the issues (diagnosis), the prognosis, and the limitations and process of therapy.  The feelings and experience of the non-identified patient- the partner need to be expressed and acknowledged.

There are increased rates of mood disorders and personality disorders among relatives of individuals with borderline personality disorder.  There were similarities in families with mood disorder and borderline personality disorder  (Smith et al., 2004, page 136).  Intimacy and dependence difficulties for the individual with borderline personality disorder is similar to the behavior of children attempting separation from parents, and as such may come from childhood separation issues.  "Masterson described the psychodynamic core of BPD as arising from the withdrawal of 'emotional supplies' by the patient's mother as he or she attempts to separate and individuate between the ages of 5 months and 3 years.  Adler and Buie postulated that the central problem for BPD patients is the failure to develop object constancy, the ability when distressed to evoke positive and soothing images of others.  This failure, they wrote, results from maternal inconsistency and lack of empathic attunement to the child" (Reich and Zanarini, 2001, page 294).  There may be specific childhood or adolescent characteristics that differentiate the individual from people with other personality disorders (page 295).  The individual with borderline personality disorder is more likely to recall significant problems being unable to handle important and brief separations.  He or she had issues tolerating frustration and managing mood fluctuations, which may be related to differences in in-born temperament.  The individual also recall many more symptoms at an earlier age.  "According to our data, suicidality, anxiety, self-mutilation, dissociative episodes, feelings of sadness or emotional pain, breaking things, or depression before age 18 may be especially good predictors of BPD in adulthood. Interestingly, anxiety before age 18 appears more closely associated with adult BPD than is depression. This finding is consistent with previous research on the affective profiles of adult BPD patients" (Reich and Zanarini, 2001, page 299).

Where'd that come from?  Childhood abuse and neglect may contribute to development of borderline personality disorder.  Joyce et al. (2003) found that 8% of individuals with no reported childhood abuse experiences developed borderline personality disorder.  However, 67% of those who experienced severe abuse did not develop borderline personality disorder.  The combination of childhood abuse with parental neglect was "a more powerful risk factor than abuse alone.  Linchan similarly believes that abuse is neither necessary nor sufficient for the development of borderline personality disorder.  Linehan uses the term 'invalidating' environment as a more general description of childhood environmental variables which interactively contributes to the development of borderline personality disorder, while we have used a narrower terminology of abuse and/or neglect. Furthermore, there is a fundamentally important interaction between abuse and/or neglect and either temperament or childhood and adolescent psychopathology" (page 762).  Wampler et al. (2004) believes that attachment theory offers guidance to understand the etiology of borderline personality disorder.  The individual may devalue or minimize current painful feelings in the relationship to old experiences with parents who dismissed the individual as a child when he or she sought comfort and support.  The individual's subsequent strategy to maintain intimacy may be to avoid directly asking for soothing.  "Reframing dysfunctional behavior in the current relationship as functional. For even necessary for survival at an earlier time is extremely useful. Such a reframe can be especially effective when guided by the extensive research that ties adult attachment strategies… to specific patterns of parent-child interaction and child attachment security" (Wampler et al., 2004, page 330).

On the other hand, while there are certain characteristics in children and teens that may be early indications of borderline personality disorder, the therapist should not assume them to be clearly predictive.  At the same time, it is not clear that intervention in childhood can prevent development of the disorder.  Nevertheless, the therapist and parents should direct energy and interventions to "ameliorate the impact of separation difficulties, high mood reactivity, and poor frustration tolerance… clinicians should inquire about symptoms in multiple areas when they are evaluating a child or adolescent who has borderline features (Reich and Zanarini, 2001, page 300).  In childhood and later in adulthood, borderline personality disorder has many potential symptoms and is often comorbid with other issues, disorders, and syndromes.  Investigation about childhood experiences may provide the developmental cues towards the diagnosis in the adult.  The therapist should also be aware of his or her attitudes, potential prejudices, and expectations of mainstream or "normal" behavior with regard to potential diversity issues.  Borderline personality disorder is more commonly diagnosed in women than in men.  The interplay of individual, family, social, and cultural experiences and expectations may create stress and emotional dilemmas for each person that the therapist needs to evaluate.  At the same time, the therapist's interplay of experiences and expectations can lead to over or mis-diagnosis of borderline personality disorder among other issues.  For example, Eubanks-Carter and Goldfried (2006) examined for differences in therapist perceptions and diagnosis of borderline personality disorder among heterosexual and homosexual males and female as well as bi-sexual males and females.  Specifically, they examined the following hypotheses:

1. Clinicians would be more likely to diagnose BPD and endorse BPD characteristics in gay and bisexual male clients than in heterosexual male clients. We also wished to examine whether clinicians would be more likely to diagnose BPD and BPD characteristics in lesbian and bisexual female clients.

2. Clinicians would rate LGB clients as being in greater need of treatment and having a poorer prognosis than heterosexual clients.

3. Clinicians would express less confidence about working with LGB clients and less willingness to treat them as compared to heterosexual clients.

4. Consistent with the findings of prior studies, we also predicted that responses to LGB clients would differ by therapist gender, with female therapists having more positive views of LGB clients and providing less severe diagnoses than male therapists.

5. Finally, we also predicted that unless participants were explicitly told that a client had a history of same-sex relationships, they would assume that the client was heterosexual. Thus, participants who received the "unspecified" male and female vignettes, in which the gender of the client's romantic partners was not stated, would assume that the clients were heterosexual, and their evaluations of these clients would not differ significantly from evaluations of clients in the male and female heterosexual conditions (page 755).

They found that there was significant influence on therapist diagnoses based on perceptions of sexual orientation with important variations based on gender.  "When therapists evaluated female clients, neither the client's sexual orientation as presented in the vignette, nor the therapist's perception of the client's sexual orientation impacted the therapists' diagnoses of BPD. When therapists evaluated male clients, however, there was a significant relation between the therapist's perception of the client's sexual orientation and BPD diagnosis. In support of our hypothesis, male clients who were perceived to have a strong likelihood of being gay or bisexual were also more likely to be diagnosed as borderline, with 61% of these clients receiving a likely BPD diagnosis as compared to only 36% of men perceived as likely heterosexual".  Overall, "therapists evaluated female clients more positively than male clients with respect to client prognosis, therapists' confidence about working with the client, and therapists' willingness to work with the client" (page 764).  This appears to correlate with a general perception of therapy as a "feminine" practice for "feminine" clients.  However,  "there were no significant differences between male and female therapists' evaluations of LGB clients"  (page 765).  They presented a vignette where the sexual orientation of the client was not specified.  Most therapists assumed that the client was heterosexual.  However, "71.4% of unspecified male clients were viewed as likely gay or bisexual, but only 4.5% of unspecified female clients were seen as being lesbian or bisexual.

This gender effect could reflect the therapists' accurate knowledge of gender differences: In the general population, more men than women report same-sex sexual behavior (e.g., Laumann, Gagnon, Michael, & Michaels, 1994). It is also possible that therapists were more likely to consider the possibility of a homosexual orientation with male clients because the client's problems and symptoms seemed to violate traditional male norms, and this led therapists to consider the possibility that the client's sexual orientation was also nontraditional."    The authors hypothesized that in the female version of the vignette where sexual orientation was not specified, therapists may have found the client's behaviors to be largely congruent with their heterocentric expectations for females. An alternate or contributing explanation for the assumption of heterosexuality comes from the concept of lesbian invisibility (page 765).  The therapist should beware that he or she may have other unspoken and unconscious perceptions relative to age, ethnicity, religion, class, and so forth that may prejudge diagnosis or render important issues invisible to the therapeutic eye.    The therapist

Be knowledgeable about statistical frequency of different populations regarding borderline personality disorder;

Be aware and responsible of counter-transference including theoretical prejudice affecting diagnosis and treatment;

Integrate temperamental or biological characteristics in the psychoeducation of the individual and the couple;

Adapting interventions and strategies based on awareness of temperamental or biological characteristics;

Explore for child abuse or neglect history when evaluating for borderline personality disorder.

Borderline personality disorder often co-occurs with mood disorders, and when criteria for both are met, both may be diagnosed.  Because the cross-sectional presentation of borderline personality disorder can be mimicked by an episode of mood disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder based only on cross-sectional presentation without having documented that the pattern of behavior has an early onset and a long-standing course.  Other personality disorders may be confused with borderline personality disorder because they have certain features in common.  It is, therefore, important to distinguish among these disorders based on differences in their characteristic features.  However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diagnosed.  Attention seeking, manipulative behavior, and rapidly shifting emotions can also characterize histrionic personality disorder.  Borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness.  Paranoid ideas or illusions may be present in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in borderline personality disorder.  Although paranoid personality disorder and narcissistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns distinguish these disorders from borderline personality disorder.

Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the concern of caretakers.  Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment, however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support.  Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships.  Borderline personality disorder must be distinguished from personality change due to a general medical condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., cocaine-related disorder Not Otherwise Specified).  Borderline personality disorder should be distinguished from identity problem..., which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder (American Psychiatric Association, 1994, page 650-54).

Treatment of borderline personality disorder can be very difficult and rarely simple.  From the diagnosis of borderline personality disorder, very little is simple.  The disorder tends not to stand alone, since it is highly comorbid with other personality disorders, as well as with "depression, anxiety, eating disorders, posttraumatic stress disorder, and substance abuse (Zanarini et al., 1999). Zanarini and colleagues (Zanarini et al., 1999) found that BPD could be depicted by a pattern of what she called complex comorbidity, characterized by multiple comorbid diagnoses that included both internalizing and externalizing disorders.  Consistently with this finding, Grilo and colleagues (Grilo, Becker, Walker, Edell, & McGlashan, 1997) found that 86% of those meeting criteria for major depression and substance abuse were comorbid for BPD.  This is particularly problematic in relation to the finding that treatment outcome studies of Axis I disorders that included comorbid BPD patients have found that BPD has detrimental effects on the treatment of the Axis I disorders—negatively affecting both the psychotherapeutic and psychopharmacological treatment efficacy for these disorders (see Clarkin, 1996).  Thus, much of what we know about empirically supported treatments for Axis I disorders can be discarded when the patient has a comorbid diagnosis of borderline personality disorder" (Levy et al., 2006, 482).  The therapist should realize that diagnostic labels are attempts to categorize clusters of behaviors that appear in an identifiable pattern or syndrome.  Within these patterns or syndromes however, there remains extensive variation.  The concept of having one diagnosed disorder versus another issue belies the individual's uniqueness.  Moreover, within each individual there are variations in responses and processing from one moment to another or from one situation to another.  There are different reactions in what appears to others as the identical situation.

Smith et al. (2004) looked at the comorbidity of euthymic bipolar disorder and borderline personality disorder as opposed to there being one condition with relationships between the two.  While both disorders are common and could occur together by chance, there are other possible explanations.  The psychosocial consequences of bipolar disorder could lead to the development of borderline personality disorder traits.  Conversely, borderline psychopathology may be primary and predispose the individual to develop bipolar disorder.  The diagnostic criteria for borderline personality disorder include what are essentially affective symptoms.  And finally, borderline and bipolar disorders may have etiological factors whether genetic or environmental in origin.  When in an active episode, individuals with bipolar disorder increase comorbidity to 60%.  Borderline personality disorder include many affective symptoms that are present during active bipolar disorder, but may not be present when non-episodal.  A personality disorder should not be diagnosed for symptoms only seen during episodes of affective illness (page 134).  "Atypical depressive features such as mood reactivity, interpersonal sensitivity, increased appetite; and hypersomnia are predictive of ultimate bipolar outcome in patients who have not previously experienced an episode of hypomania.  These features are also common among borderline patients with depression."  Other findings support the idea that an underlying cyclothymic temperament is responsible for a broad clinical phenotype including atypical depression, bipolar disorder, and borderline personality disorder.  The interaction of both biological/genetic factors- temperament and environment- childhood, family, and other experiences would explain the high comorbidity of anxiety disorders, eating disorders, alcohol and substance abuse in this diagnostic group (Smith et al., 2004, page 135).

Johnson (1991) looked at other disorders that may share borderline personality disorder symptoms or etiology.  Depression is a major aspect of borderline personality disorder such that many affected individuals come close to meeting the diagnostic criteria for a major affective disorder.  There is also strong family history of major affective disorders among individuals with borderline personality disorder.  Anti-depressant medication has been utilized for individuals with prominent affective components.  Phobic-anxious individuals with borderline personality disorder have been treated with antidepressants suggesting common underlying neurobiological bases.  Some individuals qualify for a dual diagnosis of borderline personality disorder and one or more other disorders.  In a study of 921 hospitalized borderline patients, 38 percent (n =35) had underlying neurological dysfunction (Andrulonis et al., 1981), including minimal brain dysfunction or learning disability (27 percent, n=25), and brain trauma, encephalitis, or epilepsy (11 percent, n=10).  Differences by gender were highly significant, with 53 percent (n=17) of males having a positive history for minimal brain dysfunction (MBD) or learning disability compared with only 14 percent (n=8) of females.  Females more frequently bordered a major affective disorder.

Residual characteristics of childhood attention deficit hyperactivity disorder (ADHD), formerly designated minimal brain dysfunction (MBD), also are typical of borderline adults.  ADHD often continues into adulthood and underlies such characteristics as impulsivity, irritability, poor frustration tolerance, aggressive outbursts, temper tantrums, readiness to anger, drug and alcohol abuse, distractibility, mood swings, anhedonia (diminished ability to experience pleasure), antisocial behavior, and feelings of emptiness and loneliness (Johnson, 1988).  The need for continuous stimulation often seen in these individuals arises from their attempts to escape the pain of feelings of emptiness and even depersonalization (Bellak, 1979; Hartocollis, 1977).  Electroencelphalographic abnormalities may be correlated with impulsivity, emotionality, depersonalization, and dyscontrol, arising probably dysfunction of the limbic system, a region of the brain that influences aggression, emotion, and sexual activity (Bellak, 1979) (Johnson,  1991, page 167).

The therapist will find therapy addressing one or more borderline symptoms or comorbid symptoms or complication at various times in treatment.  Anything and everything seems to become part of the therapy as they are periodically, erratically, yet consistently intrusive upon the individual's and therefore, the couple's and family's lives.  Without excellent boundaries, contingency plans, and strict follow-through, the therapist will find the "session" or "therapy" akin to being a twenty-four hour/seven day a week on call emergency room physician.  Individual, couple, or family therapy with the individual with a borderline personality disorder means taking on all the associated and differential issues within the syndrome.  The partner and family endure drama, crisis, distress, and desperation emotionally, financially, and physically at different times.  There tend to be never ending hot spots, flash fires, and eruptions to extinguish, cool down, or reconstruct that demand attention and energy.  The therapist

Should become knowledgeable about differential diagnoses of borderline behaviors;

Should treat each aspect of the individual's presentation;

Develop an unifying conceptualization that includes all aspects of the individual's and couple's experiences and behaviors;

Conduct therapy with interventions and strategies based on the theoretical conceptualization, with adaptation to the unique qualities of the individual and couple;
3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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