IMAGINE your best friend calls you at 2:00 am, or better yet, shows up knocking at your front door. When you open the door, she is in emotional turmoil, crying uncontrollably and making threatening gestures to kill herself. On closer observation, you notice her wrists are scraped and bruised. You attempt to console her once inside, and she reveals to you that her boyfriend of one month ended their “long-term” relationship over the phone and she no longer feels like life is worth living.

You are concerned but not surprised, since this is not the first instance this has happened. You tell your friend that you are there for her no matter what and she replies by saying that you better not “betray her like the others”.

If the above scenario sounds familiar, you may want to consider if your friend or relative has borderline personality disorder (BPD).

The thing is, you may not even know that he or she is suffering from a disorder and you might have brushed off her antics as her being too dramatic or even a normal response to certain situations. However, it is important to recognise that BPD is a serious mental illness characterised by severe emotional dysregulation and has a pervasive pattern of instability of self and in relationships.

Patients with this disorder usually have little control over their emotions, may have severe outbursts of crying, screaming and even making harmful gestures. There also may be repetitive self-harming behaviour such as using razors or other sharp instruments to cut themselves superficially, or refusing food.

If anyone has been a friend or is related to a person with this disorder they may recognise that the relationship is filled with insecurity and lack of trust. The person loves you one instant and in the other instant thinks you are the worst thing that ever happened to them.

Patients with BPD usually look at life as ‘black and white’ and there is no in-between. They can be incredibly impulsive, which can take a toll on family and other caregivers. Their constant need for attention and reassurance can be overbearing for even the most patient and understanding personalities. They may abuse drugs and alcohol to gain some sense of perceived control over their lives, however, this usually adds another list of problems to their slate.

Diagnosing Borderline personality disorder

The diagnosis of BPD can be difficult for even the most experienced mental health providers, however, it is important to shell out clues such as significant instability in relationships, low self-esteem, lack of impulse control, and a previous history of self harm. Many of these patients have been physically or sexually abused in childhood and have insecure attachment patterns with their primary caregivers.

The diagnosis is usually confused with major depressive disorder as many of these patients report depressed mood, hopelessness and suicidal ideations — all of which are features of depression. However, it is important to recognise that BPD is usually pervasive and maladaptive, like any personality disorder. The level of social and occupational dysfunction can have tremendous impact on the person’s quality of life.

Treating BPD

Luckily, BPD can be treated. However, treatment is no quick fix and usually requires long-term, intensive psychotherapy. The primary modality of treatment is known as Dialectical Behavioural Therapy (DBT) in which the therapist employs many techniques such as mindfulness, distress tolerance and use of imagery and relaxation techniques to improve many symptoms associated with the disorder. The idea is to give the client a sense of control and being responsible for their own decisions. They should also be able to deflect acting impulsively in difficult emotional situations by using deep breathing and relaxation techniques.

Therapy requires commitment to frequent visits and an understanding that the treatment is long-term.

The use of medication is usually limited to treating co-morbid conditions and generally target irritability and impulsive behaviour. They are discouraged as first-line agents in treatment of BPD.

In conclusion, you may be doing both your friend and yourself a favour by getting them professional help, not to mention saving thousands of dollars on late-night telephone bills.

Dr Ashish Sarangi MBBS is a resident psychiatrist at the University Hospital of the West Indies. He may be contacted via email at aks_sarangi@hotmail.com