Dolphins Brandon Marshall - borderline personality disorder

This story came through the news a couple weeks ago but I feel it's worth addressing giving the relative lack of public knowledge regarding borderline personality disorder, or many psychiatric disorders for that matter. Many people view psychiatric diagnoses as scapegoats for people to act out, behave inappropriately, etc. so I think it's warranted to clear the air.

Of course, we don't know anything about Marshall's condition so I will write in generalities for borderline personality disorder (BPD).

Borderline personality disorder - From UpToDate: "[it is] characterized by instability of interpersonal relationships, self-image, and emotions and by impulsivity. The name of the disorder was originally based upon a concept that this syndrome constituted the boundary or borderline between neurosis (a pattern of maladaptive traits and coping mechanisms) and psychosis (a condition of grossly impaired reality testing)."

What causes it? The exact suspect isn't exactly known, but likely due to a combination of factors including genetic susceptibility (i.e. family history of mental health issues), previous traumatic life experiences including those in interpersonal relationships. A number of clinical trials cite high rates of childhood sexual and physical abuse in patients with BPD. Neglect has also been correlated. (**Note: Keep in mind that there is a difference between "correlation" and "cause-and-effect").

In terms of how it manifests itself in the brain, it is still difficult to understand, but some neurotransmitter dysfunction has been seen. Again, whether this is a correlation or cause/effect pattern is uncertain.

OK, but I still don't get how these people act? The disease usually manifests itself in a number of ways:

• Interpersonal difficulties - Patients with BPD tend to have unstable relationships with close friends or romantic partners. They often alternate between idealizing somebody to seeing them as betraying or cruel. These two extremes tend to happen when the person is present (i.e. seen as perfect), or absent (i.e. seen as awful). In essence, the partner or friend is viewed as completely good or bad; this phenomenon is called "splitting". During times of strong negative emotions, the patient often thinks this person is going to leave or abandon them, leading to anger, depression, hopelessness or suicide. They also tend to see minor or neutral facial expressions, words or events as overly negative - i.e. an imagined desire that the other party wants to leave or terminate a relationship.
• Affective instability - We all have mood swings or fluctuations throughout a day but people with BPD have these to an extreme. These changes can occur within minutes, usually from environmental factors. They can alternate from explosive outbursts to someone close (from dissatisfaction) to extreme bouts of shame, guilt and worthlessness.
• Impulsivity - Patients with BPD have trouble controlling impulses. These can include binge eating, irresponsible spending of money, unsafe sex, or ending a job or relationship.

How is it diagnosed? All psychiatric illnesses are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, and can only be made by a qualified health professional. A diagnosis of BPD requires five of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. Unstable and intense relationships
3. Unstable sense of self
4. Impulsivity in two potentially harmful ways (drugs, sex, money)
5. Recurrent suicidal behaviour/self-harm
6. Unstable mood/affect
7. General feelings of emptiness
8. Difficulty controlling anger
9. Transient dissociative symptoms (i.e. temporary hiding of a memory, feeling or sensation) or paranoid ideation associated with stress

Treatment

In short, psychotherapy. Now, this isn't just your run-of-the-mill counselling or talking to somebody. It involves very deliberate direction and focus in order to be effective. UpToDate mentions a few goals or objectives that need to be reached:

• Teaching or helping with emotional regulation
• Targeting impulsivity - getting patients to observe emotions rather than feel them
• Targeting relationship difficulties - helping patients become cognizant of other people's emotions

Yeah, I know it looks pretty elementary like stuff you would see or learn about in primary school; I could try to go into details but that would require writing paragraphs of text. Basically, it's a lot more complicated than it sounds.

Drug therapy can be used in conjunction with psychotherapy - many patients receive mood stabilizers or antipsychotics. The use of drugs with BPD is a bit hazy though because patients often have other psychiatric issues like major depressive disorder, or post-traumatic stress disorder that also need treating.

So people with BPD have a rough time, I get it. But does all this diagnosing, treating, etc. really make a difference?

Yes. With proper treatment, remission of the disease was found to be anywhere from 45-54% within 2-4 years of follow-up. In one study, 93% of patients were in remission by 10 years. 86% of patients achieved remission that lasted for at least four years.

The proportion of patients with "good psychosocial functioning" (i.e. at least one close, emotionally sustaining relationship AND good work or school performance for at least 50% of the study period) increased throughout the years to up to 56% in year six.

Unfortunately, recurrence is relatively common. Loss of recovery has been in seen in 34% of people.

Sources:

Toronto Notes, 2010 edition

UpToDate