Affect

• chronic/major depression
• helplessness
• hopelessness
• worthlessness
• guilt
• anger (including frequent expressions of anger)
• anxiety
• loneliness
• boredom
• emptiness

Cognition

• odd thinking
• unusual perceptions
• non-delusional paranoia
• quasi-psychosis

Impulse action patterns

• substance abuse/dependence
• sexual deviance
• manipulative suicide gestures
• other impulsive behaviors

Interpersonal relationships

• intolerance of aloneness
• abandonment, engulfment, annihilation fears
• counter-dependency
• stormy relationships
• manipulativeness
• dependency
• devaluation
• masochism/sadism
• demandingness
• entitlement
  
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The two hallmark psychobiologic vulnerabilities or temperamental predispositions are affective instability and impulse aggression. The individual with BPD is exquisitely affectively sensitive to environmental shifts, particularly in their interpersonal sphere, so that they react with feelings of, for example, rage and despair and separation, humiliation and fury at a setback at work, etc.

It is likely that this highly sensitive affective thermostat is present from a very early age and may apparently have genetic as well as early environmental antecedents.  This affective sensitivity during the course of early development may prove a challenge to the successful mastery of the developmental tasks of childhood and adolescence. For example, an infant who is very sensitive to separation or bodily pain may cry more frequently and be more difficult to soothe when mother or other caretaker leaves, the baby may cry loudly and persistently.  

For a depressed or affectively sensitive parent, such a child can present a particularly formidable challenge. As the child grows older, these crying spells may turn into temper tantrums. For even the most empathic parent, there may be a temptation to respond to these tantrums with either excessive indulgence or at other times inattention of neglect. For the child, these inconsistent responses may constitute a sort of "intermittent reinforcement" making their temper tantrums more likely.   The temper tantrums may be the antecedents to affective storms that we may see in the borderline patient during adulthood when threatened with a potential loss of a relationship or feelings of abandonment.  by Larry J. Siever, M.D.

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Suicide: Have you attempted suicide? Why or why not? Do you have suicidal ideations? Often, or once in awhile? Under what circumstances in your life do you find that you get suicidal/or ideations?

Once I was as close as one can get to suicide without actually doing it, and I went to the hospital instead tho I don't really know why. I often have suicidal ideations. When something significant goes wrong, I think that I just don't want to live thru the pain, and that the rest of my life will be just periods of pain and no happiness, so I should die now to avoid it. This is always caused by feelings of loneliness or abandonment or having no hope for the future or that I'll never change who I am and that I am worthless.    anon.

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When I was in my late 20's and 30's, I half heartedly attempted suicide. I wanted to die at the moment but didn't have the courage to do it. I think I wanted someone to stop and stop my pain in some other way...*I* didn't know how but figured the one someone who loved me would. And if they didn't care enough to stop it, then I might as well be dead anyway. I haven't felt like actually killing myself for many years and know I wouldn't again. However, I have felt that *somehow* I wish I were dead if I lost my rock (my husband). I couldn't imagine life without him and wouldn't know what to do. Either if he left me, or if he died. That throws me into a panic. Otherwise I can handle anything else.

Diane

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Not suicidal. No suicidal ideations. I don't know why I escaped this.   V.

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Yes I have. It's not anything I'm proud of. I did because I wanted to leave. I wanted to get close to God, who is in heaven. I wanted to be with my Dad, who died 16 years ago. I wanted because I couldn't stand to be in such a big pain. My sorrow of life was overwhelming. I was not good enough for my kids (what I thought). I was not worth to be alive. I didn't know the meaning of life. I still don't. Noone liked me, I thought. I was just so depressed... There was no meaning... I rather leave myself than be left by anyone else... This is so much pain in this... I can't even describe it good enough... I didn't think things could ever get better. There was just darkness without any light at all... What's the point to stay alive then?

I still have sucidial ideations and it's hurting bad. Not as strong as before nor as often as before. But right now I'm having a rough time to talk myself into not doing such a thing again. I think I have these thoughts of suicide because I'm very tired. I haven't slept well for a while. Always when I haven't I get worse, and when I am to have my period, too. And when my therapist is gone for vacation, and when she is about to come back... When I feel loneley... When I'm very sad and can't get any rest... When I feel confused and double about things... When I get too much pressure on myself... When I don't get enough space for just me and my thoughts... When I feel unsecure about what's happening around me and my family... When I think all of the bad things that happen all over the world and in my own family... Oh, this is already getting too much....... Y.E.

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The first time I tried to commit suicide was when I was age 10 because I was terrified of being punished by my abusive parent and felt hopeless about my life ever changing. Feelings of hopelessness drove me to attempt suicide twice more when I was in my twenties. Now I simply hold the idea of it as a last resort and not something that I am likely to do.   Claudine

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SUICIDAL SELF-INJURIOUS BEHAVIOR IN PEOPLE WITH BPD
by Jessica Gerson, Ph.D., and Barbara Stanley, Ph.D.    12-4-08

Unlike other forms of self-injury, suicidal self-injury has special meaning, particularly in the context of borderline personality disorder. How is suicidal self-injury differentiated from non-suicidal self-injury in these patients, and how can their behavior be properly assessed and treated?

Borderline Personality Disorder (BPD) is characterized by unstable relationships, self-image and affect, as well as impulsivity, that begin by early adulthood. Patients with BPD make efforts to avoid abandonment. They often exhibit recurrent suicidal and/or self-injuring behavior, feelings of emptiness, intense anger, and/or disassociation or paranoia. Suicidal and non-suicidal self-injury are extremely common in BPD. Zanarini et al. (1990) found that over 70% of patients with BPD had self-injured or made suicide attempts, as compared to only 17.5% of patients with other personality disorders. Nevertheless, clinicians consistently misunderstand and mistreat this aspect of BPD. There has been considerable controversy surrounding the diagnosis of BPD, ranging from a sense that the term itself is misleading and frightening, to the fact that the diagnosis is often made in an inconsistent manner (Davis et al., 1993), to a lack of clarity about whether the diagnosis should be Axis I or Axis II (Coid, 1993; Kjellander et al., 1998). Furthermore, these patients are often excluded from clinical trials due to perceived risk. More important, however, is the fact that suicidal self-injurious behavior is usually understood within the context of major depressive disorder, while the phenomenology of this behavior within BPD is quite different. In addition, self-injurious non-suicidal behavior is often understood by clinicians to be synonymous with suicidal behavior, but again, it may be distinguished separately, particularly within the context of BPD. It is possible that, although self-injury and suicidal behavior are distinct, they may serve similar functions. This phenomenon has important implications for treatment recommendations.

Suicidality in BPD vs. Major Depression

In traditional conceptualizations developed from suicidality seen as an aspect of major depression, suicidal behavior is usually understood to be a response to a deep sense of despair and desire for death, which, if unsuccessful, typically results in a persistence of depression. Vegetative signs are prominent, and the suicidal feelings subside when the major depression is successfully treated with antidepressants, psychotherapy or their combination. In contrast, suicidality in the context of BPD seems to be more episodic and transient in nature, and patients often report feeling better afterward. Risk factors for suicidal behavior in Borderline Personality Disorder show some differences, as well as similarities, with individuals who are suicidal in the context of major depression. Brodsky et al. (1995) noted that dissociation, particularly in patients with BPD, is correlated with self-mutilation. Studies of comorbidity have produced unclear results. Pope et al. (1983) found that a large number of patients with BPD also display a major affective disorder, and Kelly et al. (2000) found that patients with BPD alone and/or patients with BPD plus major depression are more likely to have attempted suicide than patients with major depression alone. In contrast, Hampton (1997) stated that the completion of suicide in patients with BPD is often unrelated to a comorbid mood disorder (Mehlum et al., 1994) and to degree of suicidal ideation (Sabo et al., 1995).

Conceptualizing Self-Harm

Suicidal behavior is usually defined as a self-destructive behavior with the intent to die. Thus, there must be both an act and intent to die for a behavior to be considered suicidal. Non-suicidal self-harm generally implies self-destructive behavior with no intent to die and is often seen as being precipitated by distress, often interpersonal in nature, or as an expression of frustration and anger with oneself. It usually involves feelings of distraction and absorption in the act, anger, numbing, tension reduction, and relief, followed by both a sense of affect regulation and self-deprecation. Confusion in the field regarding the definition of the term parasuicide can lead to a misunderstanding of the differences in function and danger of suicidal and non-suicidal self-injury. Parasuicide, or false suicide, groups together all forms of self-harm that do not result in death--both suicide attempts and non-suicidal self-injury. Many people who engage in non-suicidal self-harm are at risk for suicidal behavior.

We propose that non-suicidal self-injury in BPD uniquely resides on a spectrum phenomenologically with suicidality. Perhaps the most distinguishing factor, as pointed out by Linehan (1993), is that self-injury may help patients to regulate their emotions--an area with which they have tremendous difficulty. The act itself tends to restore a sense of emotional equilibrium and reduces an internal state of turmoil and tension. One striking aspect is the fact that physical pain is sometimes absent or, conversely, may be experienced and welcomed, as validation of psychological pain and/or a means to reverse a sense of deadness. Patients often report feeling less upset following an episode. In other words, while the self-injury is borne out of a sense of distress, it has served its function and the patient's emotional state is improved. Biological findings pointing to relationships among impulsivity and suicidality support the notion that suicidality and self-mutilation, particularly within the context of BPD, may occur on a continuum (Oquendo and Mann, 2000; Stanley and Brodsky, in press).

It is crucial to recognize, however, that even if patients with BPD self-mutilate and attempt suicide for similar reasons, death may be the accidental and unfortunate result. Because patients with BPD try to kill themselves so often, clinicians often underestimate their intent to die. In fact, individuals with BPD who self-injure are twice as likely to commit suicide than others (Cowdry et al., 1985), and 9% of the 10% of outpatients who are diagnosed with BPD eventually commit suicide (Paris et al., 1987). Stanley et al. (2001) found that suicide attempters with cluster B personality disorders who self-mutilate die just as frequently but are often unaware of the lethality of their attempts, compared to patients with cluster B personality disorders who do not self-mutilate.

Treatment of Suicidal Behavior and Self-Injury

While non-suicidal self-harm can result in death, it is more likely not to and, in fact, only occasionally leads to serious injury such as nerve damage. Yet, patients are often hospitalized on a psychiatric unit in the same way that they would be for a frank suicide attempt. In addition, while the intent is most often to alter the internal condition, as opposed to an external condition, clinicians and those in relationships with self-injurers experience this behavior as manipulative and controlling. It has been noted that self-injury can elicit quite strong counter-transference reactions from therapists.

Although there is clearly a biological component to this disorder, the results of pharmacologic interventions have been inconclusive. Different classes and types of medications are often used for different aspects of the behavior (e.g., sadness and affective instability, psychosis and impulsivity) (Hollander et al., 2001).

One class of psychological intervention has been cognitive-behavioral therapy (CBT), of which there are a few models, e.g., Beck and Freeman (1990), cognitive-analytic therapy (CAT) developed by Wildgoose et al. (2001), and an increasingly well-known form of CBT called dialectical behavior therapy (DBT), developed by Linehan (1993) specifically for BPD. Dialectical behavior therapy is characterized by a dialectic between acceptance and change, a focus on skill acquisition and skill generalization, and a consultation-team meeting. In the psychoanalytic arena, there is controversy as to whether a confrontative, interpretative approach (e.g., Kernberg, 1975) or a supportive, empathic approach (e.g., Adler, 1985) is more effective.

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Is the girl you're dating very seductive, explosive, charming, warm, wild, ecstatic, fantasy-fulfilling and emotionally vulnerable? Does she think you have such a sweet, sexy voice?

She thinks you're the funniest guy on the planet. And you think she is so brilliant. She is absolutely without any hang ups. She enjoys just being with you. She ignores all the other men around her and fixes her gaze upon your eyes. She tells you all the stuff you want to hear. She has a remarkable talent to focus on your greatness. She has an amazing ability to mirror your attributes to appear like you. Thus, you feel an instant connection.

First phase: Her Intriguing Life Story

She engages you to her life story. The numerous stories of childhood betrayals in her life keep you intrigued. The drama in her life surpasses the TV soap operas. She starts her story as an abandoned child. She narrates how her mother was abusive. Sometimes, there is some kind of incest. Her mother left her with relatives who molested her. She also tells about a fascinating story about how her mother taught her to shoplift.

She continues her story to describe her father. He is someone she hardly knew. He was a heroin addict. He loses his temper quickly. He would indulge in alcohol and extra-marital affairs. He recalls her miserable life with him.

She remembers how her mother would sleep with different strangers. She describes them as drinking beer and smoking. In her fear, she would hide under her bed. Sometimes, she admits seeing things that a child shouldn't see.

You ask her if she was molested. She will tell you that she had no memory of certain periods in her life. Then, she suddenly has crocodile tears in her eyes which turned to unstoppable sobbing. She said that she cannot talk about it further. You tell yourself, "This poor girl doesn't deserve this life. This girl has never experienced love before. I will show her what love is. I will rescue her from her horrible life."

Second Phase: Idealization

In this phase of the relationship, she is very interested in your whereabouts. She likes to know the nitty-gritty details in your life. She adores your talents. She is interested in what you do. She puts you up on a high pedestal. You feel like a king around her. She tells you that you are everything she could possibly want in a man.

She worships you like you're the perfect guy. In her eyes, you could do no wrong. She would tie your shoe laces, fix your collar and offer to do errands. She would call you many times a day to make sure that you are alright, need anything or just praise you for being the most beautiful being in her life. She will even apologize unceasingly if it rained outside. Every inch of you matters to her. She even becomes involved in everything you like. You feel that for sure compatibility is not an issue.

Third Phase: Snares

This stage of the relationship consists of ongoing cooling off, breakups and reunions. Within the same day, she perceives you as one that could do no wrong. Her behavior shifts dramatically to the opposite. She puts words into your mouth. . Now, she assassinates your character. She spews profanities at you that you have to leave the scene especially if she does it in public places. Caught off guard, you feel resentful, angry and rejected.

The next day you feel relieved it's over. A few days after, you'll come to think of her and replay your fights. She is like a drug that you can't live without because you got used to her attentiveness and availability. You obsessively long for her return justifying what she did wrong. Then, one day she calls you about her financial, emotional and sexual predicaments. You can't resist because of suicide threats or attempts. You rescue her. She actually shows you cuts on her wrists and bruises on different parts of her body.

She felt abandoned by you, whether real or imagined. She gives you guilt about it. She wants you to idolize her or she feels unloved. Her emotions are intense. You feel important but confused. You feel overwhelming, yearning sensations to connect. Now, that she has lured you back in her life. She feels satisfied and she is pregnant.

You have second thoughts committing yourself to marriage but episodes of emotional turbulence occur so frequently. You think twice if not marrying her are causing all these turmoil. Maybe marrying her will end the nagging and pressure. Now, you feel trapped. You are in her snare.

Fourth Phase: Emotional Terrorism

In this phase, little Hitler's rules come out. Her favorite line is "I don't appreciate it when you make me wait, or when you make me do this." She can't tolerate when a pretty girl enters the room. She thinks you are definitely attracted to this girl. You exclaimed, "What girl?" She hates you for denying her truth. Then, from nowhere she shows rage and becomes hysterical.

She likes to give negative opinions on those around her. One day she might say, "Did you see how that cashier looked at me? What a bitch." She expects you to come to her defense or empathize with her. If not, she will most likely confront the girl and spew more swear words.

She likes to be the focus of your life. If anything takes you away from her such as school work, parents, friends, or job, she will torture you with negative comments about these. She sees your friends and families as threats so she talks down or belittles them. Her frequent statements are "I don't see why you have to spend time with them."

Her emotional outbursts become very frequent. She cuts or puts herself in dangerous situations to get your attention. She threatens suicide. She asks for more money. If she does not get her way, she throws things at you or physically hurt you. She challenges your manhood.

Fifth Phase: You're the Enemy and Revenge

You've had it. You cannot stand her ridicule, criticisms, rages and threats. You break away. She will seduce you back but with vengeance. She will have sex with your best friend or have an affair.

You feel like you brought this to her so you try to save her. Or, you worry about your child. But, she is now detached. If the new man is dependable and supportive, she is very prepared to leave you. You agonize on how easy it is for her to replace you.

But life doesn't end there. Negative propaganda starts within your family circle as she wants to feel justified for leaving you. She exaggerates on stories about you and intentionally lies. This is to show people that you are the villain. Her dexterity to twist facts elicits eager listeners to her woes. She is able to put sense in other people's doubts about you. Even if her statements are contradictory, she is often believed because of her acting skills. She will not hesitate to go into a smear campaign in front of an audience. Her false claims astound you for she has an amazing ability to remember in detail what people say or do and twist it for her purpose.

If you have a child with her, she will use the legal system to create real or imagined accusations. She will drain you financially. Your child is now her pawn to further control you. You are the enemy. You are the cause of her miserable life. You deserved to be punished for all the pain she feels.

Spotting the Borderline Personality Disorder Traits

Many girls with Borderline Personality Disorder have a problem with regulating their emotions. Is your new girl highly sensitive? Is she too intense? Does she shower you with too much compliments and admiration? Borderlines like to go into rebound relationships. How many relationship stories did she share with you?

Borderlines have compulsions that lead to addiction. It includes self-medication, alcohol abuse, overeating, self-mutilation, shopping sprees and sexual affairs. Did she mention any stories in her family about these compulsions or addictions?

Having highly developed logical skills, a Borderline appear very smart. She can have a stack of information at her disposable to convince you on a lot of different issues. A borderline is verbose and articulate. You are amazed at her photographic memory. They can have memories that never actually occurred. Sometimes, these memories may be intentional lies. In the long run, they believe that their lies are the truth.

In their world, there are no grey areas. Events and people are either perceived as "black or white". A borderline is jealous of your relationship with your children, mother, father, therapist, etc. It triggers abandonment emotions. They can put a wedge between you and your families and friends. She loves pitting her children, families, and friends against each other.

Conclusion

Dating is a risky game. There are red flags to take into serious consideration on your first few dates. Borderlines have intriguing life stories. They engaged you and then they skillfully find your weak spots. Then, she puts her trap. Once in her snare, you are controlled and manipulated. You will try harder to be on her good side. But, she will push you away by her constant cruel gestures and remarks.

Borderlines are near the border of psychosis. Their reality is twisted. Unfortunately, Borderlines require a psychiatric evaluation and treatment. A different approach to therapy like Dialectical Behavior Therapy (DBT) is required. It will take a lot of courage to leave a Borderline. They will not make it easy for you to leave. They will blackmail you with your weaknesses.

Just as you thought everything is over, she will engage you or "hoover", a term derived from the vacuum cleaner to represent "sucking in". Her self-worth depends on feeling connected to you. Any disappointments occurring in her life, like current love affairs or job stresses, will make her impulsively call you.

She does not know her boundaries. She is very angry at you. She will not hesitate to hurt you in the most inconceivable and damaging ways. Sometimes, an escape plan and "no contact" are the only safe options for you.

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