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Expert Q&A

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Why is my daughter's borderline personality disorder worsening?

Asked by Cindy Ackley, Roseburg, Oregon

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My daughter suffers from borderline personality disorder that appears to be worsening, even though she is now 36 years old. Treatment centers are too expensive, and her insurance will not cover it unless it is a hospital. Why would this disorder seem to be worsening -- mainly impulse control/depression -- and should she have a CT scan or other brain imaging to see if there is an underlying problem? Her primary care doctor has given up on her, and there are no psychiatrists in this town who will treat borderline personality disorder. Any help or information could help.

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Cindy,

I've got to find new ways of opening these little articles other than to express my sense of commiseration, but once again I find myself wanting to say how sorry I am to hear of your problem, especially in light of the fact that the right kinds of treatment can really make a huge difference in the lives of people with borderline personality disorder at any age. However, because BPD is a chronic, and often devastating, condition that tends to lead to alienation with treating clinicians, it is not uncommon for borderline patients to burn all their bridges in terms of getting the help they need.

BPD has been defined in many shifting ways over the years. The obvious question is, "Borderline of what?" Initially, borderline patients were seen as those who appeared to be neurotic but who began to show signs of psychosis under the stress of self-examination required by psychoanalysis. As our knowledge increased, it became clear that most BPD patients are not on the edge of a psychotic condition such as schizophrenia, but rather share much in common with various forms of bipolar disorder.

The official psychiatric handbook (the DSM-IV) describes BPD as "a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity." This can manifest in multiple ways, but the classic borderline behavior is to feel smothered by intimacy whenever others come close and to feel completely terrified about being abandoned if they move back. A classic borderline move is to dump anyone who wants you and cling desperately to anyone who wants to get away from you. No advanced degree is needed to see this is a guaranteed recipe for misery, not just for the BPD patient, but for everyone in her environment. (I use the feminine pronoun because BPD is much more common in women than men.) In addition to this terrible interpersonal dynamic, BPD patients tend to have explosive anger, rapid mood swings, self-injurious behavior (like cutting themselves), bouts of substance abuse and engagement in dangerous behavior.

Now to answer your question directly: Given your daughter's young age, it is unlikely that a brain scan will reveal anything of use, especially if she has had BPD for years. (It usually develops in the teen years.) While studies suggest that most patients with BPD improve with age, it is clear that there are many BPD patients who do not improve. All this is to say that as painful as the situation is, it is not out of the realm of the ordinary. Moreover, the 30s are the decade when most of the improvement happens in BPD, so your daughter might start doing better over the next couple of years.

It is also possible that your daughter might have bipolar disorder in addition to -- or in place of -- BPD. When I hear about mood episodes, a worsening disease course with age and a lot of impulsivity, I start wondering whether she might not benefit from medications used to treat bipolar disorder. I have seen patients with diagnosed BPD who became normal folks when their bipolar disorder was brought in line.

The other huge reason why psychiatric patients in general -- and BPD patients in particular -- begin to go downhill is substance abuse. I can't tell you how many times I've been fooled by patients who told me they were not abusing drugs or alcohol when they were. Substance abuse is "the great pretender"; it looks like everything from madness and depression to anxiety and a bad personality.

A final thought: If your insurance will cover inpatient hospitalization for your daughter, I would try to help her avail herself of this option. Inpatient treatment is the gold standard for BPD exacerbations, and nothing beats it, when it is done well.

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