Borderline Personalilty Disorder and Sexual Abuse

"Do what you want and say what you feel becausethose that mind, don't matter and those that matter, don't mind!"  

~ Dr. Seuss

If you know of any information on issues relating tochildhood sexual abuse and borderline personality disorder, please send themto: vickipolin@theawarenesscenter.org. 

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Table ofContents:

1. Borderline Personality Disorder Dignostic Criteria

2. Books

3. Resources

Also see:Self Injury/Self Harm/SelfMutilation,SuicidePrevention

A pervasive pattern of instability of interpersonalrelationships, self-image, and affects, and marked impulsivity beginningby early adulthood and present in a variety of contexts, as indicated byfive (or more) of the following:

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

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

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

5. Recurrent suicidal behavior, gestures, or threats, or self- mutilating behavior

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).

7. Chronic feelings of emptiness.

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

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

The DSM IV goes on to say:

The essential feature of Borderline Personality Disorderis a pervasive pattern of instability of interpersonal relationships, self-image,and affects, and marked impulsivity that begins by early adulthood and ispresent in a variety of contexts.

Individuals with Borderline Personality Disorder makefrantic efforts to avoid real or imagined abandonment (Criterion 1). Theperception of impending separation or rejection, or the loss of externalstructure, can lead to profound changes in self-image, affect, cognition,and behavior. These individuals are very sensitive to environmentalcircumstances. They experience intense abandonment fears and inappropriateanger even when faced with a realistic time-limited separation or when thereare unavoidable changes in plans (e.g. sudden despair in reaction to aclinician's announcing the end of the hour; panic of fury when someone importantto them is just a few minutes late or must cancel an appointment). They maybelieve that this "abandonment" implies they are "bad." These abandonmentfears are related to an intolerance of being alone and a need to have otherpeople with them. Their frantic efforts to avoid abandonment may includeimpulsive actions such as self-mutilating or suicidal behaviors, which aredescribed separately in Criterion 5.

Individuals with Borderline Personality Disorder havea pattern of unstable and intense relationships (Criterion 2). They may idealizepotential caregivers or lovers at the first or second meeting, demand tospend a lot of time together, and share the most intimate details early ina relationship. However, they may switch quickly from idealizing other peopleto devaluing them, feeling that the other person does not care enough, doesnot give enough, is not "there" enough. These individuals can empathize withand nurture other people, but only with the expectation that the other personwill "be there" in return to meet their own needs on demand. These individualsare prone to sudden and dramatic shifts in their view of others, who mayalternately be seen as beneficent supports or as cruelly punitive. Such shiftsoften reflect disillusionment with a caregiver who nurturing qualities hadbeen idealized or whose rejection or abandonment is expected.

There may be an identity disturbance characterizedby markedly and persistently unstable self-image or sense of self (Criterion3). There are sudden and dramatic shifts in self-image, characterized byshifting goals, values, and vocational aspirations. There may be sudden changesin opinions and plans about career, sexual identity, values, and types offriends. These individuals may suddenly change from the role of a needysupplicant for help to a righteous avenger of past mistreatment. Althoughthey usually have a self-image that is based on being bad or evil, individualswith this disorder may at times have feelings that they do not exist at all.Such experiences usually occur in situations in which the individual feelsa lack of meaningful relationship, nurturing and support. These individualsmay show worse performance in unstructured work or school situations.

Individuals with this disorder display impulsivityin at least two areas that are potentially self-damaging (Criterion 4). Theymay gamble, spend money irresponsibly, binge eat, abuse substances, engagein unsafe sex, or drive recklessly. Individuals with Borderline PersonalityDisorder display recurrent suicidal behavior, gestures, or threats, orself-mutilating behavior (Criterion 5). Completed suicide occurs in 8%-10%of such individuals, and self-mutilative acts (e.g., cutting or burning)and suicide threats and attempts are very common. Recurrent suicidality isoften the reason that these individuals present for help. These self-destructiveacts are usually precipitated by threats of separation or rejection or byexpectations that they assume increased responsibility. Self-mutilation mayoccur during dissociative experiences and often brings relief by reaffirmingthe ability to feel or by expiating the individual's sense of being evil.

Individuals with Borderline Personality Disorder maydisplay affective instability that is due to a marked reactivity of mood(e.g., intense episodic dysphoria, irritability, or anxiety usually lastinga few hours and only rarely more than a few days) (Criterion 6). The basicdysphoric mood of those with Borderline Personality Disorder is often disruptedby periods of anger, panic, or despair and is rarely relieved by periodsof well-being or satisfaction. These episodes may reflect the individual'sextreme reactivity troubled by chronic feelings of emptiness (Criterion 7).Easily bored, they may constantly seek something to do. Individuals withBorderline Personality Disorder frequently express inappropriate, intenseanger or have difficulty controlling their anger (Criterion 8). They maydisplay extreme sarcasm, enduring bitterness, or verbal outbursts. The angeris often elicited when a caregiver or lover is seen as neglectful, withholding,uncaring, or abandoning. Such expressions of anger are often followed byshame and guilt and contribute to the feeling they have of being evil. Duringperiods of extreme stress, transient paranoid ideation or dissociative symptoms(e.g., depersonalization) may occur (Criterion 9), but these are generallyof insufficient severity or duration to warrant an additional diagnosis.These episodes occur most frequently in response to a real or imaginedabandonment. Symptoms tend to be transient, lasting minutes or hours. Thereal or perceived return of the caregiver's nurturance may result in a remissionof symptoms.

Associated Features and Disorders

Individuals with Borderline Personality Disorder mayhave a pattern of undermining themselves at the moment a goal is about tobe realized (e.g., dropping out of school just before graduation; regressingseverely after a discussion of how well therapy is going; destroying a goodrelationship just when it is clear that the relationship could last). Someindividuals develop psychotic-like symptoms (e.g., hallucinations, body-imagedistortions, ideas of reference, and hypnotic phenomena) during times ofstress. Individuals with this disorder may feel more secure with transitionalobjects (i.e., a pet or inanimate possession) than in interpersonalrelationships. Premature death from suicide may occur in individuals withthis disorder, especially in those with co-occurring Mood Disorders orSubstance-Related Disorders. Physical handicaps may result from self-inflictedabuse behaviors or failed suicide attempts. Recurrent job losses, interruptededucation, and broken marriages are common. Physical and sexual abuse, neglect,hostile conflict, and early parental loss or separation are more common inthe childhood histories of those with Borderline Personality Disorder. Commonco-occurring Axis I disorders include Mood Disorders, Substance-RelatedDisorders, Eating Disorders (notably Bulimia), Posttraumatic Stress Disorder,and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorderalso frequently co-occurs with the other Personality Disorders.

Specific Culture, Age, and Gender Features

The pattern of behavior seen in Borderline PersonalityDisorder has been identified in many settings around the world. Adolescentsand young adults with identity problems (especially when accompanied by substanceabuse) may transiently display behaviors that misleadingly give the impressionof Borderline Personality Disorder. Such situations are characterized byemotional instability, "existential" dilemmas, uncertainty, anxiety-provokingchoices, conflicts about sexual orientation, and competing social pressuresto decide on careers. Borderline Personality Disorder is diagnosed predominantly(about 75%) in females.

Prevalence

The prevalence of Borderline Personality Disorder isestimated to be about 2% of the general population, about 10% among individualsseen in outpatient mental health clinics, and about 20% among psychiatricinpatients. In ranges from 30% to 60% among clinical populations with PersonalityDisorders.

Course

There is considerable variability in the course ofBorderline Personality Disorder. The most common pattern is one of chronicinstability in early adulthood, with episodes of serious affective and impulsivedyscontrol and high levels of use of health and mental health resources.The impairment from the disorder and the risk of suicide are greatest inthe young-adult years and gradually wane with advancing age. During their30s and 40s, the majority of individuals with this disorder attain greaterstability in their relationships and vocational functioning.

Familial Pattern

Borderline Personality Disorder is about five timesmore common among first-degree biological relatives of those with the disorderthan in the general population. There is also an increased familial riskfor Substance-Related Disorders, Antisocial Personality Disorder, and MoodDisorders.

Differential Diagnosis

Borderline Personality Disorder often co-occurs withMood Disorders, and when criteria for both are met, both may be diagnosed.Because the cross-sectional presentation of Borderline Personality Disordercan be mimicked by an episode of Mood Disorder, the clinician should avoidgiving an additional diagnosis of Borderline Personality Disorder based onlyon cross-sectional presentation without having documented that the patternof behavior has an early onset and a long-standing course.

Other Personality Disorders may be confused with BorderlinePersonality Disorder because they have certain features in common. It is,therefore, important to distinguish among these disorders based on differencesin their characteristic features. However, if an individual has personalityfeatures that meet criteria for one or more Personality Disorders in additionto Borderline Personality Disorder, all can be diagnosed. Although HistrionicPersonality Disorder can also be characterized by attention seeking, manipulativebehavior, and rapidly shifting emotions, Borderline Personality Disorderis distinguished by self-destructiveness, angry disruptions in closerelationships, and chronic feelings of deep emptiness and loneliness. Paranoidideas or illusions may be present in both Borderline Personality Disorderand Schizotypal Personality Disorder, but these symptoms are more transient,interpersonally reactive, and responsive to external structuring in BorderlinePersonality Disorder. Although Paranoid Personality Disorder and NarcissisticPersonality Disorder may also be characterized by an angry reaction to minorstimuli, the relative stability of self-image as well as the relative lackof self-destructiveness, impulsivity, and abandonment concerns distinguishthese disorders from Borderline Personality Disorder. Although AntisocialPersonality Disorder and Borderline Personality Disorder are both characterizedby manipulative behavior, individuals with Antisocial Personality Disorderare manipulative to gain profit, power, or some other material gratification,whereas the goal in Borderline Personality Disorder is directed more towardgaining the concern of caretakers. Both Dependent Personality Disorder andBorderline Personality Disorder are characterized by fear of abandonment,however, the individual with Borderline Personality Disorder reacts toabandonment with feelings of emotional emptiness, rage, and demands, whereasthe individual with Dependent Personality Disorder reacts with increasingappeasement and submissiveness and urgently seeks a replacement relationshipto provide caregiving and support. Borderline Personality Disorder can furtherbe distinguished from Dependent Personality Disorder by the typical patternof unstable and intense relationships.

Borderline Personality Disorder must be distinguishedfrom Personality Change Due to a General Medical Condition, in which thetraits emerge due to the direct effects of a general medical condition onthe central nervous system. It must also be distinguished from symptoms thatmay develop in association with chronic substance use (e.g., Cocaine-RelatedDisorder Not Otherwise Specified).

Borderline Personality Disorder should be distinguishedfrom Identity Problem...which is reserved for identity concerns related toa developmental phase (e.g., adolescence) and does not qualify as a mentaldisorder."

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Books

• I Hate You - Don't Leave me:  Understanding the Borderline Personality

Resources

• Borderline UK

• BPD Central

• BPD Recovery

• BPD Sanctuary

• The Sidran Institute - Traumatic Stress Education and Advocacy