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Q: What interventions do you recommend to reduce the likelihood that a child who has experienced abuse or neglect will develop borderline personality as an adult?
Dr. Gold: I want to thank you for posing questions about primary prevention. Generally, the psychiatric community is focused on symptom reductions and relapse prevention. It is important to recognize that children exposed to abuse and neglect are at risk for developing a variety of personality disorders. Family instability and lack of parental affection and supervision during adolescence have been found to predict dependent and passive-aggressive personality disorder. Childhood maltreatment is also associated with the development of anti-social personality disorder in early adulthood.
Sexual abuse, physical abuse and neglect are correlated with the development of borderline personality disorder. Unfortunately, little is known about exactly how to prevent the development of BPD. Obviously, the first step is to intervene swiftly and put an end to the abuse and neglect. If possible, the child should be referred for long term psychotherapy, not solely short term crisis counseling. The victimized child will need a consistent, safe adult figure with whom to explore the trauma. It is felt that children who are unable to be thoughtful about their own mental states and those of others are more likely to develop borderline personality disorder. Children who have been abused by trusted adults are often inhibited about thinking about the actions of their perpetrators. Our goal is to give these children safe role models to assist them in thinking about their own mental states. We want to discourage compartmentalization and denial and encourage a healthier sense of self and substantive interpersonal relations.
There are a few proven therapeutic modalities for a child or adolescent who has begun to engage in self destructive or suicidal behavior. It is imperative to screen these adolescents for post-traumatic stress disorder (PTSD) since it is often mistaken for BPD. PTSD can be treated much more successfully in short-term therapy and with SSRIs. If a primary care provider is concerned about BPD, the patient should be referred to a mental health professional with a possible recommendation for dialectical behavior therapy. DBT is a good option for kids who are self-destructive and have failed other modalities. DBT is a strict behavior therapy that aims to improve interpersonal effectiveness, emotion regulation, distress tolerance and mindfulness. It works to directly reduce self-destructive thoughts and behavior. Primary care professionals can assist adolescents in locating DBT programs that are often found in academic centers but usually have long waiting lists.
Q: What preventive measures can be taken-by primary care providers and/or mental health professionals-to protect the mental health of a child whose parent has BPD?
Dr. Gold: Living with a parent who has BPD is very challenging since we look to our parents for stability and consistency. The hallmark of BPD is a pervasive pattern of instability in interpersonal relationships, self-image and affects. These children require a consistent, stable adult figure whether it is a pediatrician, a therapist or relative. I have seen children of BPD parents successfully meet their developmental milestones by simply being in therapy with a consistent, stable clinician who is not impulsive and who is able to model healthy interpersonal relationships. It is also helpful if the parent is encouraged to seek his or her own treatment to assist them in the challenging task of parenting. Family therapy can be useful as the child gets older but the child should not be expected to share his therapist with his parent.
Peter Fonagy, a British psychoanalyst, has written a great deal about the need for children to have secure attachments with their parents and to learn how to "mentalize" in order to prevent the development of BPD. Primary care providers can intervene early with BPD parents to assist them in child rearing and to encourage them to develop a positive relationship with their infants. Mentalization is the capacity to think about mental states in oneself and in others. This type of reflective awareness is lacking in BPD parents and their children must find it elsewhere. Finding willing relatives or enrolling kids in big brother/big sister programs can help. However, these people must be willing to spend significant time with the kids over an extended period time. I recommend a caring counselor or therapist who can serve as a surrogate parent until the child is able to mentalize on his own and has learned how to manage and accept the limitations of his parents.
Recommended resources:
1. Peter Fonagy et al. Affect Regulation, Mentalization and Development of Self. Other Press: August 2002.
2. Marsha Linehan. Skills Training Manual for Treating Borderline Personality Disorder. Guilford Press: 1993.
Q: What are some of the challenges and rewards in working with difficult patients with borderline personality disorder?
Dr. Prakash: There are numerous challenges. The biggest challenge is making a clear distinction between the patient and his or her illness. A classic example of failure to meet that challenge is when we identify an individual as a "borderline patient." (I am very impressed with the way in which the questioner phrased this question: ".difficult patients with borderline personality disorder.") Stigma, treatment resistance, lack of resources, suffering of loved ones, and self-defeating behavior comprise only an incomplete list of various challenges we all face in caring for patients with BPD. Comorbidities that commonly exist compound the inherent challenge. Inconsistency has been a way of life for these patients, and ensuring consistency in their lives is a tall order.
The split-care arrangement, in which a patient sees multiple clinicians in different settings, invites "splitting" - a habit of alternately idealizing and vilifying others, including caregivers, which is characteristic of borderline personality disorder. Without integrated systems of care, providers may not recognize idealization as part of this pathological defense mechanism; if missed, it is not a reward, but a risk.
The true rewards of working with these patients are internal. They begin with accepting the challenge to work with individuals who have difficult problems such as BPD. For many of them, the past is history that can not erased, and the future is a mystery that cannot be solved; there is only today, and as clinicians, we are part of that reality. Life can be understood only backward, but must be lived forward. Compensating these individuals today with the gift of hope for tomorrow is reward enough.
Q: Given the similarities in symptoms of borderline personality disorder, posttraumatic stress disorder and early recovery from drug/alcohol abuse, how can primary care providers distinguish among these disorders in homeless patients, and how should clinical approaches to such patients differ?
Dr. Prakash: Indeed, there is significant overlapping among borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and substance use disorders. Mood disorders and psychosis can also co-exist with these conditions. Because comorbidities are the rule rather than the exception in our homeless clientele, we must keep our eyes and ears open to other comorbidities as the diagnostic evaluation progresses. Simply speaking, if the mind doesn't know, the eyes do not see. Not infrequently, PTSD becomes apparent only after a few visits when the patient has begun to trust us and open up - when the therapeutic relationship is well established. Clearly, there are major challenges in distinguishing these disorders that test our diagnostic acumen all the time. While the DSM-IV offers us operational criteria for differential diagnoses, exclusive reliance on these criteria may be hazardous. The bottom line is, primary care providers can help identify some of these elusive conditions early on by keeping a keen eye on possible comorbidities, just as they do when a patient presents with diabetes, and soon other ailments - hyperlipidemia, coronary artery disease and hypertension - are picked up.
Clinical approaches to these disorders differ. Psychotropic medications have a well-defined role in the treatment of PTSD, mood and psychotic symptoms, which can be associated with BPD and chemical abuse. By relieving these co-occurring conditions, pharmacotherapy may also have favorable effects on personality and addictive behavior. Two other points are worth remembering: First, psychotherapy is a very effective tool for all of these psychopathologies, except in cases of blatant psychosis. Second, an integrated, concurrent approach to the treatment of multiple, co-occurring disorders is more effective than a sequential one (treating one problem first, then another). This is especially true with homeless clients, who are best served by delivering all needed care under one roof ("one stop shopping"), thereby avoiding financial and other obstacles to care in multiple locations.
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Rudra Prakash, MD