Interviewing the Borderline Patient

Shona Ray, M.D. PGY-I

Borderline Personality Disorder

Becomes worse with intensive psychotherapy They would develop psychosis Borderline phenomena are ubiquitous and can be found in many pts Stable instability of emotions, relationships, ego functions, and identity Women between ages 20 and 50 Subsides over the course of the life cycle

DMS-IV Diagnostic Criteria

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following
Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation Identity disturbance: marked and persistently unstable self-image or sense of self Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behaviors, gestures, or threats, or self-mutilating behavior Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger Transient, stress-related paranoid ideation or severe dissociative symptoms

Borderline Characteristics
Affective instability Unstable interpersonal relationships Sexuality Identity disturbances Rejection sensitivity Impulsivity Self mutilation and suicidality Paranoid ideation and dissociation

Affective instability
Episodes of depression and dysphoria of short duration Anger = altered state of consciousness in which reasoning, reality testing, and an awareness of feelings of other people no longer exist Unrequited , feelings of love and sexual desire occur early in relationships Affect storms: emotional outbursts with intense aggressive and demanding quality directed at therapy

Unstable interpersonal relationships

Initial idealization of another person will be followed by devaluation and denigration Intense involvement after superficial encounter Idealization=manifestation of craving to be loved/desire to be idealized in return Capacity to delay gratification or inhibit impulsive anger is impaired

Sexuality
Sexuality is not inhibited (histrionic) Protagonist in seduction

Identity disturbance
Seek identity based on the responses of others Need for outside world to provide psychic structure is the root of the patient's incessant craving for emotional responses from other people Sexual and gender issues Sudden, impulsive vocational changes

Rejection sensitivity
Fear of rejection is often a self-fulfilling prophecy Alone=fear and confusion

Impulsivity
Often self destructive or life threatening Drugs and alcohol used in desire to feel more alive or real Impulsive change in friends/jobs! Display to cause the other person to feel guilty

Self mutilation and suicidality

Indication of severe nature of disorder Self-mutilative behaviors double the likelihood of successful suicide in future Concrete manifestations of inner psychic pain Reassure a person of boundaries between self and outside world

Paranoid ideation and dissociation

Belief that he/she is being cruelly mistreated defends against an even more painful inner feeling of inadequacy Misperceptions or cues and misunderstandings are common Real external stressors can lead to paranoid convictions Depersonalization Derealization

Differential diagnosis
Diff dx: borderline pd, narcissistic pd, bipolar d/o, other personality d/o Comorbidities: depression, alcohol, other substance abuse, bipolar disorder (maybe variant of bipolar II)

Borderline vs. Narcissistic

Both idealize and devalue others Borderline alternates but cares Narcissist exploits and discards Narcissist rage is a contemptuous nature when exploitation is no longer possible Borderline rage is response to threat to pts dependency (not grandiosity)

Developmental psychodynamics
Genetic endowment and early experience Genetic: easily aroused anger and low frustration tolerance A stable sense of self and an integrated internal image of the caretakers are contingent upon experiencing consistent empathic responses from the parenting persons. The normal attachment of the child to the parent facilitates the capacity to perceive mental states in the self and others. The guilt of the abuse following the abuse that leads to the abuser acting warm, tender, and caring. A patter is laid down associating abuse with love!

Developmental psychodynamics
Superego: my behavior is justified because I have been treated badly is the underlying subtext. Boundaries were often transgressed by parents. Unconscious desire to relieve a traumatic incestuous experience is motivated by the guilty pleasure that it originally invoked and a wish to master the desire, to turn passive into active and not bee helpless in the face of remorseless yet stimulation abuse.

The Interview
Negative and disturbing countertransference Less disturbed pt will seem easy to interview and appear to be perfect psychotherapy pts Borderline pts look normal on structured psych test such as Wechsler Adult Intelligence Scale but psychotic on Rorschach.

Exploration of the presenting issues

Sensitive exploration The pts incessant desire to receive reinforcing confirmation may play difficult demands on an interviewer The interviewers desire to maintain an empathic stance constrains him from contradicting the pts view of the world which is often marked by externalizations, contradiction, and denials of personal responsibility. Empathically recognizing her sense of hurt or distress without joining the pt in agreement is appropriate response

Exploration of the presenting issues

Enter idealized phase WARNING: Remain dispassionate because flattery will turn into the opposite

Early confrontations
Must explore impulsive and frequent self destructive behaviors Need to avoid being condemnatory Place it in a context that gives it meaning Self-mutilation: Ask to see marks! This will bring the hidden masochistically and erotically induced behaviors into the light of day. Its no longer secretly hidden and can be looked at objectively with its meaning explored. Must set limits

Early confrontations
Female borderline pt uses sexual means to express lack of boundaries Male borderline pt uses nonsexual means (money, stock market tips) to express lack of boundaries Must state you do not need this information but they seem eager to share. Sets limits and emphasizes the theme of therapy-exploring motives that underlie impulses rather than acting on them

Early confrontations
Early desires to discuss transference based dreams or erotic fantasies will occur Deep interpretations based on insightful early material are potentially disastrous because the pt does not possess the ego strength to integrate such interpretations and may have a paranoid and rageful response. Early management necessitates an empathic, supportive but in many respects noninterpretive posture.

Transference and countertransference

Pts will insist on an immediate emotional connection to assuage the emptiness and inconsideration that persist in their childhood memories. A rapid idealization of the clinician is common and is potentially seductive if it is taken at face value. Expect devaluation and continue to express a sustained, empathic, supportive posture Offer a long term example that the pt can experience an emotionally important individual, the therapist, can possess both virtues and faults Self monitor countertransference! This is crucial to maintaining the parameters of the clinical situation and will obviate the boundary violations that can occur. Use supervisory consultation

Conclusion
Clinician will experience stormy tempests, blurring of ego boundaries, emotional hunger, erotic stimulation, and fluid self-states. Inner whirlwind experience by clinician is a powerful tool An even, empathic, and supportive posture in early phase can consolidate the development of a more stable sense of self in the pt, lead to a more integrated internal view of other people, diminish self destructive behavior, and open the way for more directly interpretive work.