Roots in childhood
The flurry of research on borderline personality disorder is casting the condition in a new light. Originally, the behavior was blamed on abuse, trauma or neglect in childhood. But newer research suggests that people with the disorder are born with the predisposition to be emotionally sensitive. Abuse puts a person at higher risk for borderline personality disorder but not everyone who develops it is abused or neglected.
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"Parents commonly say, my kid has not been normal since he or she was born," says Dr. Marianne Goodman, a psychiatrist at Mount Sinai School of Medicine in New York.
In a study presented at the American Psychiatric Assn. meeting, Goodman found signs of emotional sensitivity in young children who were later diagnosed with borderline personality disorder. Via a Web questionnaire, Goodman collected data from parents on 234 people with the disorder and 87 unaffected siblings.
She found that as infants, the children who were later diagnosed with borderline personality disorder tended to be self-soothing -- they sucked their thumbs or had attachments to objects, such as a blanket -- compared to unaffected siblings. They were also more sensitive, had excessive separation anxiety and were moodier. They had social delays in preschool and many more interpersonal issues in grade school, such as few friends and more conflicts with peers and authorities.
As teenagers they were more promiscuous, aggressive and impulsive, and more likely to use drugs and alcohol. Cutting and suicide became common.
"Children are really starting to look so different at that point," Goodman says.
Other research shows that, by their 20s, people with the disorder are almost five times more likely to be hospitalized for suicidal behavior compared to people with major depression.
Research on the brains of people with the disorder suggest there is a biological predisposition to the core symptoms of emotional sensitivity and misperceiving the actions and feelings of others.
For example, a study published in 2008 in Science showed different patterns of brain activity in people with the disorder: The scans showed abnormal responses in a brain region called the bilateral anterior insula when borderline personality patients played a game with other people that tested their sense of fairness and social norms.
Through such studies, experts say, it is becoming clearer that the condition may simply be a type of personality that some people enter the world with. Some describe that mind state as a "pervasive emotional dysregulation" -- a brain that is primed to overreact.
"I don't think you can learn to be borderline," Linehan says. "They are intensely emotional people. The sensitivity to emotion is probably there at the beginning."
By emphasizing a biological tendency to the behavior, therapists and family members say they hope to soften the perception of the borderline patient as willfully manipulative and argumentative.
"BPD is very popular in terms of literature, the media and movies," says Dr. Josepha A. Cheong, the 2009 chairwoman of the American Psychiatric Assn.'s scientific program committee. But it often gets bad -- and inaccurate -- press in such media, she adds.
One of the most prominent portrayals is the maniacal stalker played by actress Glenn Close in the movie "Fatal Attraction." A more accurate portrayal, Cheong suggests, would be the character of Jenny in the movie "Forrest Gump," who was a somewhat sympathetic but self-destructive, dysfunctional woman who wanted a normal life but couldn't achieve it.
"It's a far more compassionate portrait," Cheong says. "It hints at the suffering of the patient."
Future progress in helping people with borderline personality disorder, however, may rest on the willingness of therapists to recognize it and apply therapies that are specific to the condition. One study of 70 patients presented at the American Psychiatric Assn. meeting found that 34% had been given a wrong diagnosis before finally being identified with borderline personality disorder.
The study also found that 74% of people who met the criteria for the disorder had never been diagnosed with the condition despite an average of more than 10 years since their first encounter with a psychiatrist.
The correct diagnosis is key because specific behavior-change therapies seem to work best (see related story.)
There are several helpful therapies, experts say, notably dialectical behavioral therapy, and all share common elements. The bond between the patient and therapist is strong -- important for a long-term, therapeutic relationship. And the therapy focuses on the present rather than the past, on changing one's behavior patterns now regardless of how patients feel about the past or if they see themselves as victims.
After Sooki's diagnosis, her mother Patricia began to change the way she communicated with her daughter by remembering that Sooki is ultra-sensitive and easily misperceives others' feelings.
Sooki began seeing a therapist who specialized in borderline personality disorder. She attended group support meetings, took medication for depression and began to exercise to battle her depression in a positive way. She is now in a healthy relationship with an understanding, supportive boyfriend, her mother says, and is taking college classes.
She doesn't yet tell people she has borderline personality disorder because, she says, few people understand what it is.
But, recently, she has started telling the truth about the scars on her arms. "The scars from my cutting are a reminder of how bad things were," she says.
"For so long I felt like an outsider looking in. I hated myself, she adds. "I've really improved and I think each year will get better."