Research suggests that addiction is often the consequence of inadequate caregiving during critical periods of childhood development. Insecure bonding is thought to result in substance abuse, with alcohol being the most prominent and used to manage emotional dysregulation that results from adverse childhood experiences (Choca, 2011). However, substance abuse alone is not the only result of attachment related injuries. One hallmark psychiatric disorder that is known to be a direct result of trauma, neglect, and abuse in childhood is Borderline Personality Disorder (BPD). BPD will be featured in this research paper due to its prominent association with early attachment deficits and accompanying anxiety that has altered the formation of one’s personality. A multitude of self-harm and addictive behaviors are often found in individuals with this diagnosis, thus prompting research to help understand and alleviate the damaging effects that BPD inflicts both interpersonally and on society at large.
Etiology. Through evidenced based research, it is known that as soon as a human being is born, their experience within their social and emotional environment begins to shape their personality. This lays the foundation for the development of one’s perceptions of life events and how, in turn, one views themselves. As such, early experiences greatly impact one’s ability to sustain healthy relationships and thrive as members of a collective social group (Corey, 2005). Louis Cozolino, the author of Neuroscience of Human Relationships, describes in detail how the effects of social interaction develops neuropathways within the brain and how each section of the brain is affected by life experiences (Cozolino, 2006). These findings shed light on the formation of attachment and how one is affected from the damaging effects of trauma, abuse, and persistent neglect (Cozolino, 2006).
To delve further into the neurological measures of the human condition one must look at how neurobiology and interpersonal experience work together and greatly contribute towards the shaping of the human mind. Daniel Siegel, author of The Developing Mind, writes of the impact of nature versus nurture and shows us how personality is developed, even neurologically altered by the varied experiences that each individual encounter, beginning at birth (Siegel, 1999). Siegel examined how care giving interactions with young children can profoundly transform and shape a child’s ability to have successful interpersonal relationships in their future. The argument, often known as nurture versus nature, is frequently discussed, debated, and studied. Recent findings within a 50-year twin study indicate that 49% of personality coming from hereditary factors and 51% coming from environmental influences (Polderman, Benyamin, Leeuw, et.al. 2015).
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From what is known today, it is understood that attachment is one of the most important elements necessary for humans to thrive within a society. Secure attachments are vital to neuronal growth which directly affects one’s mental functioning and establishes a foundation that influences the ability to have relationships. A person’s social environment affects the development of the brain by activating responses that trigger neuropathways to develop, which in turn, creates human behaviors and interactions (Cozolino, 2006). Cozolino illustrated this by stating “…always remember that neurons are embedded within our brains, as our brains are embedded in our bodies, as our bodies are embedded in society, and so on up the chain of complexity (Cozolino, 2006). This all ties into motivation, cognition, and emotion through early life experiences when people learn how to get their needs met, what successful and negative consequences were required to achieve life sustaining needs, and how to manage, perhaps even manipulate, one’s world. The result of these experiences may lead to the development of personality disorders.
Borderline Personality Disorder: Disorders of the personality are a separate category within the DSM V and are described as “…long-term patterns of thoughts and behaviors that are unhealthy and inflexible. The behaviors cause serious problems with relationships and work. People with personality disorders have trouble dealing with everyday stresses and problems” (Medline Plus, 2017). Of the personality disorders, Borderline Personality Disorder (BPD) is considered a serious mental health condition which is characterized by a group of symptoms that represent poor emotional regulation and mood instability (Harvard Health Education, 2000). Those symptoms are widely described as follows: poor self-image, feelings of emptiness, difficulty coping when alone, intense moods, anger, irritability, and markedly unstable relationships. Individuals with BPD struggle with impulsive behavior, substance abuse, suicidal ideations, and self-harm behaviors which may include, cutting, burning, and other self-mutilating practices. When symptoms are severe, a person with BPD may experience distorted thinking, excessive anxiety, panic, and psychotic episodes (Harvard Health Education, 2000).
BPD is most commonly considered a disorder caused by varying forms of trauma with as many as 81% of BPD patients reporting a history of neglect, emotional, physical, and sexual abuse in early childhood (Baird, 2008). A person with BPD may experience inadequate bonding by primary caregivers which creates an attachment injury, leaving an individual to question self-worth, struggling to find value in oneself, and intense fear of abandonment. In a 2009 study, reported by Current Psychiatry, indicates the suicide rate amongst Borderline individuals as 3.8% and earlier studies reported 8%-10% suicide rates, which is approximately 50 times that of the average population (Berk, Grosjean, Warnick, and et.al. 2016). Additionally, BPD is one of the costliest conditions to treat, as individuals with BPD tend to over utilize medical and emergency systems (Cummings and Cummings, 2012).
A multitude of triggering events can increase the symptomology of a Borderline patient. The most common is the fear of perceived abandonment and rejection. Due to this intense fear, relationships for a BPD patient tend to be tumultuous, destructive, and fraught with difficulties, as the slightest misstep by the partner of a BPD individual can be perceived as rejection. As such, manipulation is considered a trait of BPD as a person with BPD very existence depends on the approval of those within close relations (Harvard Health Education, 2000).
The motivation to compete for social acceptance is high amongst BPD patients; however, due to poorly developed ego- strength, BPD individuals struggle with typical fluctuations found within interpersonal relationships (Corelli, n.d). BPD individuals report feelings of intense loneliness, even when being involved in a close intimate relationship (Harvard Health Education, 2000). The very goal and motivation of the BPD patients is to obtain and secure attachment; however, their volatile and inconsistent emotional lability is counterproductive to obtaining said goal, thus generating a cycle of abandonment and interpersonal upheaval.
A greater prevalence of depression and anxiety has been found in individuals with BPD as studies have shown that a diagnosis of depression, as defined by the DSM-IV-TR, are at 22.4% and anxiety rates at 15.2% (Kraus, Schafer, Csef, et al., 2000)., whereas in the general population positive depression scores normally run around 6.7% (NIMH, 2010). In addition to depression and anxiety, patients who have been diagnosed with BPD also show higher incidence of alcohol, opioid, and cocaine related abuse (Salters-Pedneault, 2018).
Alcohol and Borderline Personality Disorder. As with many types of psychiatric disorders, substance abuse is often co-occurring and is thought to be used as a means of self-medication to alleviate psychiatric symptoms. BPD is often, if not always, accompanied by anxiety and difficulties with emotional regulation (Chocha, 2011). Dr. Pedro Chocha PhD of Arizona State University reports that alcohol is seen with individuals who have anxiety, due to its depressant qualities. Alcohol acts as a means of lowering anxiety, has calming properties, and with its ease of accessibility makes it readily available for use. Alcohol abuse is the number one substance of choice with 63% of BPD individuals having been diagnosed with alcohol dependence disorder (Salters-Pedneault, 2018).
There is a remarkable overlap between substance abuse disorders and borderline personality disorder. One recent study found that about 78% of adults who have been diagnosed with BPD will also have a co-occurring substance use disorder at some time in their lives, meaning the symptoms and course of BPD and the substance use disorder occur at the same time (Salters-Pedneault, 2018).
While BPD is widely considered a trauma related disorder, there is some evidence of a genetic component. Salters-Pednault PhD, reports findings that indicate BPD and alcoholism may share common genetic pathways. This may indicate that genes that put people at higher risk for BPD may also create higher risk for alcoholism (Salters-Pednault, 2018). As previously stated, the next contributing factor is environmental as the maltreatment experienced in childhood leads to susceptibility to alcohol abuse and later dependence. The combination of these two factors both increase the likelihood of the development of both conditions. Finally, a third reason potential reason for the link between alcohol abuse and BPD is that alcohol decreases the intense emotional feelings that BPD individuals struggle to regulate
Compulsive Self Harm Behaviors and Borderline Personality Disorder: In a recent article found in Psychology Today explains that three-quarters of those with BPD engage in self-harm behaviors; however, a study in 2008, indicated numbers as high as 90% (Sack, 2015). Self harm behaviors are considered to be self-destructive actions that include: cutting, burning, hitting, hair-pulling, head-banging, and skin picking (Sack, 2015). These behaviors are non-suicidal gestures, instead are employed to shift mental pain to physical pain, express anger, frustration, stress, to self-punish, and are a cry for attention (Sack, 2015).
In a study published by the National Institute of Health finds “a number of risk factors were found to be associated with self-mutilation, including borderline personality disorder, alcohol dependence, childhood sexual abuse, and multiple suicide attempts. Not only is self-mutilation a clinically significant problem, but when combined with a history of attempted suicide, the psychological dysfunction observed is markedly high” (NIH, 2011). The combination of alcohol consumption and poor impulse control, place BPD individuals at high risk of self-harm behaviors.
As such, with the co-occurrence of alcohol abuse and BPD, the incident of self-harm behavior greatly increases. BPD individuals are known to have poor impulse control, this combined with alcohol which acts as a further inhibitor of impulse control, elevates the risk self-harm. The combination of these three elements contribute greatly the severity and distress of BPD individuals, which consequently adds another element to the difficulty in treating the disorder.
Within the medical and psychiatric communities, it is known that the need for proven outcome measures for borderline personality disorder is greatly needed. Harvard Review of Psychiatry claims that “Borderline Personality Disorder accounts for nearly 20% of all psychiatric hospitalizations and outpatient clinic admissions, but only three percent of the research budget of the National Institute of Mental Health” (Harvard Review of Psychiatry, 2016). The same article goes on further to say “the level of psychosocial morbidity and suicidality associated with BPD is as great, or greater, than that experienced by patients with bipolar disorder” (Harvard Review of Psychiatry, 2000). As such, it is thought that BPD treatment and diagnoses should be given as much attention as bipolar disorder, due to BPD presenting just as large of a public health concern.
Presently, the most widely used treatment options for BPD are psychotherapy, dialectical behavior therapy (DBT) which utilizes mindfulness techniques, medication, and hospitalization. Success is most commonly seen when BPD patients are able to fully engage a multitude of services and maintain treatment for an extended period of time. A medication protocol varies based on the severity of the symptoms that the patient is experiencing. However, the most commonly utilized medications are SSRI’s, Tricyclics, and MAOI. The purpose of these medications is to reduce the symptoms of “…affective dysregulation and impulsive-behavioral dyscontrol, particularly depressed mood, anger, and impulsive aggression, including self-mutilation” (Oldham, et.al. 2010). Interestingly enough, an unexpected finding was that with the use of these medications a reduction in impulsive behavior and aggression was seen shortly after the pharmaceutical intervention began; however, there was no reduction in anxiety and depression reported (Oldham, et.al. 2010). This finding implies that depression and anxiety are independent from aggression and impulsivity (Oldham, et.al. 2010).
The significance to this understanding the correlation between BPD, alcohol abuse/dependence, and self-harm behaviors provides better treatment options that will assist BPD patients towards better psychiatric health. It is through the mastering, via understanding one’s emotions and increasing awareness and attention to the nature of one’s mind that individuals can begin to reshape the way the brain functions. By doing so, people can begin to experience a more harmonious existence due to the reduction of opposing structures playing against one another. The end result includes healthier relationships, a cultivation of positive emotions, and the ability to master our lives. This is in stark contrast to a life of one being held hostage emotions that can be overwhelming when left unmanaged. The ability to rewire and change one’s thought patterns is the key to compassion, empathy, and understanding other’s internal world as well.
The interest in this topic stems from this writer’s early experience with Borderline Personality Disorder and the lack of skill possessed to treat these patients. My first place of employment after graduate school was within a county jail facility that housed 700 inmates. Of those 700, there were 550 males and 150 females. The majority of the females and to a lesser degree, many males, carried the BPD diagnosis. I was new in the field and did not have the skill to treat these individuals. Most were enraged, inflamed, manipulated staff and each other. For a long time after having left the position, I did not want to work with BPD patients. My own anxiety increased, and I felt inept, just waiting for the escalation of behaviors to begin.
After starting this degree, I decided to move towards my vulnerabilities and where I needed the most work. Therefore, whenever there is an assignment or research article, I try to further my knowledge and understanding of BPD, so that I can be a better clinician to this population. My knowledge has grown exponentially. I continue to learn about the causes, treatments, and protocols for BPD patients. While I cannot say that I enjoy the work any more or that my treatment outcomes are any better, I can say that I do understand it more thoroughly. This has provided me with more empathy and understanding with those individuals inflicted, as truly it is typically horrific starts in life that have created it. No fault of their own.
References
- Bonding and Substance Abuse – PubMed
- Effects of social interaction on brain development – American Psychological Association
- Borderline Personality Disorder: Symptoms & Causes – Mayo Clinic
- The association between childhood trauma and addiction – National Center for Biotechnology Information
- Borderline personality disorder and drug addiction: Epidemiology and treatment – American Psychological Association
- Borderline Personality Disorder – National Institute of Mental Health
