Calm the emotional storm

Borderline Personality Disorder often falls into the schism between psychosis and neurosis, writes Dr Alok V Kulkarni

Ramona (name changed) was a 36-year-old entrepreneur, with impulsive anger outbursts, frequent threats of harming herself, difficulties with her spouse, family members and friends, and intense crying spells lasting for hours on end. In the face of an imminent crisis, she sought help during the peak of the pandemic. Upon further evaluation, it was found that she had attempted many ‘deliberate self-harm’ attempts wherein she would try to make cut marks over her wrists. This was a frequent occurrence following a tiff with her spouse. She would lock herself in a room and violently bang on the door threatening suicide. During the sessions that followed, it was evident that Ramona’s worldview fit into the classical "all good" or "all bad" phenomenon. Some people were perfect according to her, while a few others were extremely bad. And these descriptions were frequently interchanged. At times, she worshipped the very same people who she otherwise criticised. It was also established that Ramona had had a string of failed relationships, and she feared being cut off from people she loved. She would idealise her friends on some days and after a few days, she would devalue and berate them. Her values and ideas about people changed dramatically and quickly. After a comprehensive and holistic clinical assessment, it was deemed that Ramona could possibly have borderline personality disorder. Borderline personality disorder is an illness characterised by an ongoing pattern of varying moods, unstable self-image and rapidly changing behaviour. Impulsive actions are at the core of this disorder. These impulsive actions bring about a multitude of problems in interpersonal relationships.

People with borderline personality disorder will experience intense episodes of anger, depression and anxiety. These can last from a few hours to days. People with this disorder make frantic efforts to avoid real or imagined abandonment. This may take the form of rapid initiation of intimate (either physical or emotional) relationships or blocking communication with someone in anticipation of being abandoned. There will be a consistent pattern of unstable interpersonal relationships often swinging from extreme intimacy and love (idealisation) to extreme dislike or hatred and anger (devaluation). This psychological mechanism is called ‘splitting’. Impulsive behaviours, such as spending sprees, unsafe sex, substance misuse, binge eating and reckless driving may be seen.

There will be recurrent thoughts of suicide or self-harming behaviours, such as cutting oneself. This will be accompanied by chronic feelings of emptiness. A person having this disorder may have chronic feelings of emptiness. Persons may also experience a deep sense of mistrust which is termed as “paranoia”. This may be accompanied by an irrational fear of other people’s intentions. This results in a high degree of unwarranted threat perception. Lastly, one may feel as though one is cut off from oneself, may see oneself from outside one’s body or have feelings of unreality. It is important to know that not everyone will experience all the above-described symptoms. Some may experience only a few of these symptoms while others may have many symptoms. Ongoing research in neuroscience suggests the role of a bevy of factors in the causation of this vexing clinical condition. A positive family history, brain factors, environmental, social and cultural factors modulate the risks associated with developing this disorder. Most people with this disorder report having experienced painful events, traumatic childhood, abuse, abandonment or other adversities. Although these factors may increase the risk of developing this disorder, it does not mean that every person with these adversities will develop borderline personality disorder.

In Ramona’s case, a comprehensive clinical interview, a thorough physical examination and a few laboratory tests were run to rule out other possible organic causes. Special attention was paid to Ramona’s usage of alcohol and nicotine, which she had resorted to, as unhealthy coping mechanisms. Following this, Ramona was advised in-patient care for 12 weeks, to which she agreed after a tad bit of convincing. During this period, a special form of counselling called Dialectical Behavioural Therapy was initiated. Ramona was empowered with skills to tolerate her distressing situations without indulging in self-harming behaviours. The cycle of cutting herself during periods of imminent crises was finally broken through the skills transferred during these counselling sessions. Ramona was also started on a low-dose antidepressant to tide over her depressive symptoms.

(The author is a mental wellness expert & senior consultant psychiatrist.)