Transcription
For the benefit of my long-suffering students, this video contains, in one location, in one place, all the latest research about borderline personality disorder—cutting edge, bleeding edge, sadistic (pun intended). I reviewed the literature in the past two years; I assembled everything, and here you have it: the borderline Bible.
My name is S. Vagin. I'm the author of *Malignant Self-Love: Narcissism Revisited*. I'm a professor of psychology at CEAPS Commonwealth Institute for Advanced Professional Studies in Cambridge, United Kingdom. I'm also a professor of psychology, or visiting professor of psychology, at CU Southeast European University, and I'm a former visiting professor of psychology for five years at Southern Federal University in Russia—yes, the Russia that is becoming the United States' best friend ever, its bestie. Talking about borderline, talk about borderline personality disorder. Okay, let's get serious.
At the end of this video, I'm going to review the alternative model of borderline personality disorder in the text revision of the Diagnostic and Statistical Manual, fifth edition. But before we get there, let me summarize what we know hitherto. Borderline personality disorder is a pervasive disorder. It's pervasive in the sense that it insinuates itself and permeates every cognition, every emotion, every behavior of the individual afflicted. Generally speaking, we regard borderline personality disorder more behaviorally than otherwise, and the behavior is characterized by unstable interpersonal relationships, problems with self-image and affect, as well as impulsive self-harming behavior.
Now, the term borderline personality, actually “borderline group,” was first coined by Adolph Stern in 1938. He attempted desperately to describe a group of patients who were clearly not psychotic and, on the other hand, not neurotic. And so he said they belong to a border group or a borderline group, and so he coined this immortal phrase. Much later, in the 70s and 80s, borderline personality disorder was all the rage. Scholars such as Otto Kernberg have studied it in depth and have contributed immensely to our understanding.
According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision, in 2002, a diagnosis of borderline personality disorder requires the presence of five or more of the following characteristics or diagnostic criteria: Number one, frantic efforts to avoid real or imagined abandonment. The diagnostic and statistical manual neglects to mention engulfment anxiety, which is the second, the twin anxiety in borderline. We have separation insecurity or abandonment or separation anxiety coupled with engulfment anxiety, and this leads to approach-avoidant behaviors. The borderline seeks intimacy, craves love, yet when she gets it, when she gets these from her partner—intimacy, love, friendship, and presence—she recoils and she runs away. This is known as approach-avoidance repetition compulsion. There is a fear of intimacy; actually, the borderline feels suffocated, shackled, imprisoned, incarcerated, coerced when she's confronted with a partner who is willing to satisfy her needs for closeness. And so this is this—this is a much-neglected aspect of borderline personality disorder in the DSM.
The second diagnostic criterion is a pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization, in which a person assigns exaggeratedly positive characteristics to the self or to others, and devaluation, in which a person assigns exaggeratedly negative characteristics to the self or to others. This is commonly referred to as splitting; it's an infantile defense mechanism.
The third criterion is identity disturbance or identity diffusion, with a markedly and persistently unstable self-image or sense of self or self-concept. Impulsivity in at least two areas that are potentially self-damaging and reckless: example, spending, sex, substance abuse, reckless driving, binge eating, and so on. Recurrent suicidal behavior, gestures, or threats, or self-mutilating and self-harming and self-trashing behavior.
Next is affective instability due to marked reactivity of mood. Now, that sounds very complex, very serious. It simply means that the borderline's emotions overwhelm her, and so she is emotionally unstable, volatile, whereas her moods cycle up and down between euphoria and dysphoria, depression, and sometimes mania. So there is a reactivity of mood: example, intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days.
The next criterion involves chronic feelings of emptiness. I've dwelt on the issue of emptiness in borderlines and in narcissists. I've—I've um—analyzed it and expanded on it using the writings of numerous psychoanalysts in a series of videos on this channel. Simply look for the word “empty” or “emptiness.” Inappropriate intense anger or difficulty in controlling anger. This is called externalized aggression: for example, frequent displays of temper, constant anger, recurrent physical fights. This should be distinguished from the reactive narcissistic rage in narcissists.
And the last criterion involves transient stress-related paranoid ideation or severe dissociative symptoms. How many people—how many people are we talking about? What is the prevalence of borderline personality disorder? Well, the only reliable figures we have are from the United States, and 2.7% of the population suffer from a borderline personality organization which is—which is sufficiently severe to qualify as a borderline personality disorder. The figures are 3% for women and 2.4% for men, but this seems to be culturally biased, seems to be a culture-bound number, and in all likelihood, half of all borderlines are men.
The American Psychiatric Association cites a lifetime prevalence of BPD in the United States as anywhere between 1.4% and 2.7%. In psychiatric settings, the estimate is 15% to 28%. In other words, anywhere between 15% and 28% of people who present themselves to a therapist or a psychiatrist in clinical settings are likely to have um borderline personality disorder. Data from family studies have demonstrated the prevalence of borderline personality disorder among first-degree relatives of affected patients is four to 20 times higher than in the general population. In other words, if you have borderline personality disorder, if it’s four to 20 times more—you four to 20 times more likely to have a first-degree relative with borderline personality disorder than in the general population. This is a powerful indicator that there is a hereditary, genetic component in borderline personality disorder.
The ways in which the personality patterns of the borderline are generated are diverse, multifactorial. In other words, there is no single developmental path that leads inexorably to borderline personality disorder. Many factors interact. I've mentioned genetics; then we have environmental factors in the pathogenesis of borderline—in other words, in the path that has led to the emergence of a—of a pathology in borderline. We've identified um assuredly childhood maltreatment, adoption, maternal separation, poor maternal attachment, dead mother, inappropriate family boundaries including incest, parental substance abuse, sexual abuse, and serious parental psychopathology. Post-traumatic stress disorder often co-occurs with borderline personality disorder, and one therefore can speculate or surmise that borderline personality disorder is a post-traumatic condition. Eminent scholars such as Judith Herman, the mother of complex trauma, CPTSD, and others have suggested that borderline personality disorder, albeit marked mainly with emotional dysregulation, is actually a form of complex trauma. This is not accepted in the mainstream, but it is an interesting proposition. In my own work, much before Herman, actually, I—I have been proposing for well over 30 years that both narcissistic personality disorder and borderline personality disorder are post-traumatic presentations.
Certain genetic factors, as I mentioned, probably play a role. We have data from twin studies that show that the heritability of borderline personality disorder is probably around 40%. Studies found a higher concordance of borderline personality disorder in monozygotic than dizygotic twins. So how does—how do these genes express? How do they manifest? How—what—what is it that they affect, especially in the brain? We know that there are alterations in the social reward and empathy networks of the brain, called caused by the dysregulation of the oxytocinergic system, and we believe—we are increasingly more convinced that it somehow contributes to the emergence of borderline personality disorder. But again, to this very day, 100 years later, the emphasis is still on nurture rather than nature. The belief—common belief among clinicians, especially who’ve been exposed to patients with borderline personality disorder, is that environmental factors are the crucial determinants of pathogenesis, the ones I’ve mentioned before.
Um, clinicians should be—should be um—aware that the Diagnostic and Statistical Manual provides two ways of diagnosing BPD. There is the copy-pasted list of nine agnostic criteria from the fourth edition, and there is the alternative model, which I will discuss at length a bit later. So we have a categorical model and a dimensional model. BPD, conventionally, to this very day, and I would add regrettably, is still diagnosed using a categorical model. In other words, the prospective patient either does or does not receive a diagnosis by meeting five out of nine criteria. A dimensional model of diagnosis characterizes the condition based on a spectrum of prominent traits, which is a much more realistic and agile, versatile approach to mental illness.
The nine diagnostic criteria um create a problem known as the polythetic problem. You could have two patients: patient number one meets the criteria numbers—numbers 1, 2, 3, 4, and 5. So you have a patient—the nine criteria, and this patient satisfies conditions number one to five. Then you have another patient, and this patient satisfies conditions 5, 6, 7, and 8—5, 6, 7, 8, and 9, I’m sorry. So you have two patients; they’re both diagnosed with borderline personality disorder, and yet they share only a single diagnostic criterion. In other words, the variance is enormous; presentations vary significantly among patients having ostensibly the same condition. The categorical approach is often used with a dimensional—in conjunction with a dimensional approach in an—an attempt to remedy this variation, to counter the polythetic or solve the polythetic problem—problem. But I think the only correct approach is to dump—to forget the categorical list, the antiquated, may I add, categorical list, which is about 40 or 50 years old, and to move on completely to the dimensional model, which is a lot more descriptive and a lot more real life—a lot more realistic.
One approach that may prove useful in performing a dimensional diagnosis in—of BPD is the Five-Factor Model. The Five-Factor Model describes personality on a continuum—continuum, and there are five characteristics: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. I’m sorry, I’ve just added three days with two mega interviews each day. I don’t have much of a voice left. And so it’s been demonstrated that borderline personality disorder can be differentiated from other mental health condition or mental illness or personality disorders based on specific differences in Five-Factor Model traits. Similarly, in the International Classification of Diseases, 11th Edition, which is the diagnostic textbook—diagnostic manual used by 80% of humanity and is the main competitor of the DSM, there—there—there’s a list of trait domains, and a combination of the trait domains—these combinations give rise to the equivalence of personality disorders in the DSM. Although borderline personality disorder shares many characteristics with bipolar affective disorders, they are entirely distinct diagnostic entities.
But before I go there, because of the structure—the categorical structure of the—of the DSM, especially the fourth edition, text revision, and the fifth edition, we have a situation where people are diagnosed with multiple personality disorders combined with mood disorders, substance abuse disorders, anxiety disorders, and so on and so forth. It’s very common for an individual attending therapy or clinical settings to end up being diagnosed with six or seven or eight conditions. That is untenable.
Now, online self-styled experts spew all kinds of nonsense: for example, that 40% of all borderlines are also diagnosed with narcissistic personality disorder. That is explicitly untrue; that’s not correct. However, it is true that in about one-third to 40% of borderline personality disorder diagnoses, there is another attendant condition, which could be a personality disorder, but more frequently is a substance abuse disorder or a mood disorder—a dual diagnosis.
I want to focus on bipolar disorder because I’m shocked by the level of ignorance of clinicians and alleged scholars, especially in Europe, when it comes to the distinctions between borderline personality disorder and bipolar disorder. I have come across um professors of psychology in, for example, Austria, clinicians in Austria, psychiatrists in Austria who can’t tell the difference between bipolar disorder or bipolar disorders and borderline personality disorders, confuse the two and misdiagnose patients on a—on a massive scale, industrial scale. This is really bad. It is true that both conditions—bipolar disorders or bipolar affective disorders and borderline personality disorders—it’s true that in both conditions there are dramatic shifts in mood. However, the timing, the duration, the intensity, the pattern of the mood shifts is very, very different. And in addition to that, there are clinical features in borderline personality disorders that never appear in bipolar disorders. Borderline personality disorder is characterized by affective instability—I’m quoting—“a marked reactivity of mood: example, intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days.” That’s not the case with bipolar disorders. In bipolar disorders, there are episodes of affective extremes—high highs and lows—and these episodes last for days as a minimum; much more commonly, they last for weeks or they can take months. Patients with borderline personality disorder shift from euthymia—a good feeling—to anger, whereas patients with bipolar disorder tend to shift from depression to elation or from depression to mania.
Although borderline personality disorder and bipolar disorders are different conditions, it is possible, of course, to have both of them; they—it’s possible that they occur concomitantly in the same individual, but they’re not the same disorder. Another differentiating factor between borderline personality disorder and bipolar disorders is sleep. There are sleep disturbances in both these conditions. Patients with borderline personality disorder experience an increased sleep onset latency, low sleep efficiency, and nightmares. Patients with—with bipolar disorders experience a reduced need for sleep—not merely disturbances in sleep or decreased sleep, but no need to sleep whatsoever during a manic episode, and on the contrary, during a depressive episode, they would experience excessive sleepiness, hypersomnia. So the—in these two realms, which are mood reactivity and sleep patterns, we already see massive differences between bipolar and borderline. And then, of course, there’s a complete list of other clinical features which make an appearance in this diagnosis or that diagnosis, but not together, not in both.
Clinicians should be aware of the ego-syntonic nature of borderline personality disorder behaviors. We should make a distinction between behavior per se and the outcomes of behaviors. Borderline personality patients report having experienced shame and guilt, remorse, and regret. These are reported by borderline patients, and they’re not reported, for example, by narcissistic patients or by psychopaths, of course. And yet the regret and the remorse and the shame and the guilt often revolve around the outcome—the consequences of a specific behavior, not the behavior itself. As far as the borderline is concerned, the behavior is justified; all behavior—all behaviors are justified. It’s—it’s just the unfortunate outcomes of these choices, decisions, defiance, consciousness, rejection of authority, recklessness—the unfortunate outcomes of self-trashing, self-harming, harming others, externalized aggression—these outcomes are rejected; these outcomes are grieved over, mourned, and there is—then there are—then negative effects such as shame and guilt.
Personality disorders generally consist of ego-syntonic patterns of behavior. Very few people with personality disorders reject their personality disorder. A narcissist, for example, does not feel bad about being a narcissist. A borderline doesn’t feel bad about being a borderline. A psychopath, of course, doesn’t. So ego-syntony is very common in personality disorders, and this is on the conscious level. Unconsciously, of course, many—in many of these personality disorders, there is an internalized bad object. In other words, unconsciously, there may be the feeling that one is—that the—the—the patient may possess the feeling that he or she is unworthy, a failure, a loser, ugly, stupid, um unlovable, and so on, but that would be unconscious. Consciously, these people are happy-go-lucky, essentially. The problematic conduct exhibited by a borderline is not inherently distressing to the person performing it. The patterns may feel natural, justified, or even reflexive and instinctive. So borderline personality disordered people, they’re not ego-alien; they’re ego-congruent; they’re not ego-alien. In other words, their personality feels to them natural, acceptable. It is important, however, to make the distinction that the consequences of ego-syntonic behavior may well become very distressing for such a patient, even if the performance of the behavior or the choice of the behavior is not distressing. So this distinction is very important when you diagnose um borderline personality disorders.
By contrast, mood disorders such as major depression or bipolar disorders, they’re typically ego-dystonic. The behaviors are or ultimately become inherently distressing to the person who exhibits these behaviors or acts this way. So here is a diff—here is an important differentiating feature or criterion: borderlines don’t feel bad about their actions; they feel bad about the consequences of their actions, whereas people with bipolar disorder feel bad about their actions. Personality disorders consist of ego-syntonic patterns of behavior, not ego-dystonic patterns of behavior—not ego-dystonic ones.
Okay, um, how do we treat borderline personality disorder? Not with medication; that’s a common misconception, especially online. There are no medications approved by any authority that I’m aware of—definitely not by the FDA in the United States. There are no medications specific to borderline personality disorder, although there are medications which treat features of borderline personality disorders, such as, for example, depression or an—an obsessive-compulsive features. Typically, borderline personality disorder is treated with different forms of psychotherapy. There are many approaches to borderline personality disorder, and most of them—what is common to most of them, for example, schema therapy and so on, is to emphasize the self-efficacy, the sense of self-efficacy and sense of self-worth of a patient. So they teach patients—these treatment modalities teach patients to recognize what triggers their affective reactions. Patients are also encouraged to connect actions to thoughts, to feelings, to consequences—a sequence that is often disrupted in borderline personality disorder, narcissistic personality disorder, and other personality disorders.
One frequently recommended approach is, of course, dialectical behavior therapy, DBT. This is by far the most efficacious method or treatment modality we have with borderline personality disorder and the recommended one by me as well. Dialectical behavior therapy is a widely used and effective form of cognitive behavior therapy that—um—um—uh—where we treat borderlines resemble dialectical behavioral therapy clinically speaking. Technically speaking, dialectical behavior therapy is cognitive behavior therapy modified because it involves also a group—a group setting. The um DBT targets suicidal and self-harming behavior using eight treatment strategies: Number one, dialectical strategies foster the patient’s ability to accept reality as it is. Modifying personality—it disorder, as much as narcissistic personality disorder, is about the rejection of reality or, at the very least, the outsourcing of reality to an intimate partner or a special person. Owning reality, accepting it, living in it, is a crucial treatment—treatment plan goal. Therapists accomplish this through the use of myth and paradox, a focus on reality as constantly changing, the non-resolution of ambiguity—learning to live with ambiguity, be comfortable with it—and cognitive challenging and restructuring.
A second element in DBT is problem-solving: a variety of strategies that support the patient’s ability to recognize sources of distress and address them in an adaptive way—not a maladaptive way. Validation strategies utilize empathy, non-judgmental acceptance, and the patient’s own resources. Irreverent communication strategies call for the therapist to respond in a matter-of-fact, irreverent way to the patient’s suicidal tendencies—not to panic, not to—definitely not to chastise or criticize the patient, not to react in any emotional way, but to deal with a suicidal ideation, sometimes with suicidal threats, matter-of-factly, with a cool head and with irreverence—not to elevate or um—the suicidal act or the suicidal ideation into some kind of ideology or religion, to give it—to give it respect. Such strategies are in direct, constant uh contrast to validation strategies.
Consultant strategies emphasize the therapist’s role as a consultant to the patient. The therapist in DBT has an active role; he—he doesn’t just sit back; he doesn’t just mirror the patient or—or—but the therapist in DBT is a friend of the patient, an active participant in the patient’s—participant—the patient’s life. The therapist, for example, gives the patient uh advice; it’s—it’s not—it’s a partnership in—in the full-fledged sense, and in many ways, the therapist becomes a consultant to the patient, but also kind of friend by proxy or vicarious friend. Um, the idea is for the therapist to work with the patient in a way that creates some kind of emotional alliance. So the consultant, in the case of DBT, is less attuned to other treatment professionals which may be dealing with the patient and more to the patient—is more on the patient’s side.
Capability enhancement strategies serve to keep patients engaged in acquiring and practicing skills required to cope with everyday life. Everyday life in borderline personality disorder is very overwhelming and may lead to mood disorders and—and substance abuse disorders and so on. And so teaching the borderline patient skills on how to deal with daily life and how to develop self-efficacy, how to obtain outcomes which are either desired or beneficial—this is a crucial aspect of DBT. Relationship strategies emphasize building a strong patient-therapist relationship, as I’ve mentioned, and the belief is that addressing interpersonal problems within this relationship between therapist and patient, as they arise, learning to apply these skills to other relationships in the patient’s life might ultimately lead to the permanent, lifelong acquisition of the ability to interact with other people in ways which are not dysfunctional or harmful. So in other words, the relationship between the patient and the therapist or the consultant in DBT is the prototypical relationship. The patient then learns to take this relationship and all the lessons that he—it had wrought and applied to other relationships with a consultant is absent. It is, in a way, a reenactment of childhood where the patient is allowed to grow through the interaction with the consultant. The consultant fulfills the equivalent of a parental role.
Continence strategies involve the therapies being upfront with a patient about what outcomes reasonably can be expected from the therapy. There’s no exaggeration of the potential benefits of the therapy. So borderline personality disorder may be treated adjunctively with medication when appropriate. There are no medications approved—I repeat this—it’s not true what you hear online that there—there are cures for borderline personality disorder, let alone narcissistic personality disorder. There is a broad spectrum of pharmacologic agents—psychopharmacology—um—psychopharmacological medications that can be used to address specific symptoms or presentations—for example, antidepressants. There’s been a review of randomized controlled trials, and they found that—uh—certain antidepressants were effective in decreasing symptoms of depression, hypersensitivity in interpersonal relationships, and obsessions in patients with borderline personality disorder. Citalopram, I think, was one of them. Among mood stabilizers, topiramate and um—lamotrigine and so on and so forth, they were shown to reduce anger in patients with borderline personality disorder. Even antipsychotics um—olanzapine, for example—were found to reduce anger, paranoia, anxiety, and interpersonal sensitivity in patients with borderline personality disorder.
Again, coming back to the core—core clinical observation, treating borderline with medications has limitations—not small limitations—whereas some patients with borderline may respond to various medications initially, very few respond satisfactorily over an extended period; specifically in borderline personality disorder, medications are even less effective than in the general—general population or in other conditions. The duration of a—of pharmacological treatment should be time-limited; there should be an ongoing review, um, and then the medication should be stopped when it’s no longer effective.
Borderline personality disorder is a lifelong condition, but the prognosis varies widely. We know that there is spontaneous healing or spontaneous losing of the diag—of the diagnosis later on in life. We know that DBT is very effective. Diagnostic criteria and standards have changed over time, and presentations may vary widely among patients. So predicting outcomes with precision is very difficult. Research has shown that early-onset borderline is associated with poor functioning in adolescence. We know that much. So if someone is—develops symptoms of borderline personality disorder around the age of 12, the adolescence of such a person is likely to be highly chaotic and disturbed and dysfunctional and problematic. Evidence also suggests that the course of adolescent-onset borderline is similar to that seen in adult populations. In other words, the later the borderline develops—the later the borderline disorder develops, the better the prognosis.
The rate of suicide associated with borderlines is estimated to range between 3% and 10%, depending on the cohorts and the populations and the age groups and the countries and the cultures and the societies and the religious affiliation and so on and so forth. We could generalize and say that uh the rate of suicide in borderline personality disorder is definitely closer to 10% than to 3%. Many people who qualify for a diagnosis of borderline personality disorder um also commit suicide before presentation—before they’ve attended therapy, before they presented themselves to a clinician. We strongly suspect that suicide is highly associated—highly correlated with borderline personality disorder in non-diagnosed people. People go through life sometimes without ever coming to clinical attention. It’s not uncommon to diagnose borderline personality disorder in one’s 30s or 40s or even 50s. Evidence indicates that early diagnosis and intervention improve patient outcomes. The prognosis for borderline personality disorder is good if you begin to work on yourself and attend, for example, DBT early on, like in your 20s or your teens. Here, unfortunately, borderline personality disorder very rarely presents in its purity; it’s very rarely unadulterated by other conditions. So most people with borderline personality disorder, for example, abuse substances. Comorbidity there is very high, and these people have…
An increased risk of suicide and substance dependence/substance abuse is commonly observed in patients with borderline personality disorder. Higher rates of comorbid psychiatric disorders are also seen in patients with BPD, including mood disorders (particularly major depressive disorders), anxiety disorders, and eating disorders. Patients with borderline often experience sleep disturbances, as I mentioned, and so the picture is severely complicated by these comorbidities.
Um, let us now um try to explore the new approach to borderline personality disorder that is embodied in the um, in the um Diagnostic and Statistical Manual; in the alternative model of borderline personality disorder, which is dimensional. I'm going to read to you what the DSM alternative model has to say, because I think every word counts. It's a distillation of the latest knowledge. It's regrettable that clinicians still use the DSM-IV's list of bullet points because it's antiquated, does not reflect current knowledge, and does not capture many aspects of borderline. So here it is: the alternative model.
Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affect, accompanied by impulsivity, risk-taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domain of negative affectivity and also antagonism and/or disinhibition.
Proposed diagnostic criteria in the Alternative Model:
A. Moderate or greater impairment in personality functioning manifested by characteristic difficulties in two or more of the following four areas:
Area number one: Identity—markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism, chronic feelings of emptiness, and dissociative states under stress.
Area number two: Self-direction—instability in goals, aspirations, values, or career plans.
Area number three: Empathy—compromised ability to recognize the feelings and needs of others, associated with interpersonal hypersensitivity (in other words, prone to feel slighted or insulted), hypervigilant perceptions of others (selectively biased toward negative attributes or vulnerabilities).
Area number four: Intimacy—intense, unstable, and conflicted close relationships marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment. Close relationships are often viewed in extremes of idealization and devaluation, and alternating between over-involvement and withdrawal.
B. Four or more of the following seven pathological personality traits (at least one of which must be impulsivity, risk-taking, or hostility):
Number one: Emotional lability (an aspect of negative affectivity)—unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
Number two: Anxiousness (an aspect of negative affectivity)—intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, and/or threatened by uncertainty; fears of falling apart or losing control.
Number three: Separation insecurity (an aspect of negative affectivity)—fears of rejection by and/or separation from significant others, associated with fears of excessive dependency and complete loss of autonomy.
Number four: Depressivity (an aspect of negative affectivity)—frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
Number five: Impulsivity (an aspect of disinhibition)—acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or without consideration of outcomes; difficulty establishing or following plans; a sense of urgency; and self-harming behavior under emotional distress.
Number six: Risk-taking (an aspect of disinhibition)—engagement in dangerous, risky, and potentially self-damaging activities unnecessarily and without regard to consequences; lack of concern for one's limitations; and denial of the reality of personal danger.
And finally, number seven: Hostility (an aspect of antagonism)—persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
This delectable clinical picture encapsulates perfectly all the aspects, psychodynamic and behavioral, of the borderline patient. Have fun! e e e