Borderline is a personality disorder. But it is above all a very broad concept, says Professor Benedicte Lowyck of the University Psychiatric Center in Leuven. The DSM-5, the classification system that maps all mental disorders, stipulates nine characteristics under the lemma ‘borderline’. Anyone who meets five of these can be diagnosed. “The DSM-5 is a descriptive diagnostic system. So you mainly look at the things that are present on the surface that you can observe,” says Lowyck.
Which immediately indicates: it goes further than that. “A simple definition of borderline is difficult. In addition to those five or nine criteria, there are 256 ways to have a borderline problem. I prefer not to call it a disorder. Rather, it’s on a spectrum. Disorder sounds too negative to me.”
Borderline is therefore not a simple matter. The name alone. Borderline, a thin line on the edge. The edge of what? “The name dates from the middle of the last century, when a distinction was mainly made between psychotic and neurotic problems. Two psychoanalysts, Robert Knight and Adolph Stern, found that people with such a problem were not psychotic, but neither were they neurotic. They were balancing on the edge between the two. Hence: borderline.”
But what is it? “Having less feeling about a situation, an unstable self-image, instability in interpersonal relationships, which often involves too close, too far, or attraction and repulsion. In short: people with borderline have difficulty regulating their affection and often have very intense emotions very quickly, which cloud their thinking. But letting those emotions subside again is not easy.”
“A simple definition of borderline is difficult. There are 256 ways to have a borderline problem”
Benedicte Lowyck
Professor at borderline-expert
“Pressure,” Professor Lowyck calls it. “Especially with negative emotions, although I don’t like to use that term. Let’s say: the emotions that bother them the most. Fear, anger, … The burden of suffering that this entails can be very high. And related to that, there is a great fear of abandonment. And a feeling of emptiness. ‘Who am I, what am I actually doing here?’”
Self-harm is also said to be common among people with borderline. Is that right?
(nods) “Impulsiveness is also such a criterion. Self-mutilation, injuring oneself, can be a consequence of this. Just like suicide attempts, which you can also see as a form of self-harm. But it could just as well be drug or alcohol use. That is all related to the very strong emotions. The pressure of suffering becomes so high that they want to stop it. In a way that is self-destructive.”
“Without minimizing or denying those criteria or symptoms, I think it is much more important to look at the underlying dynamics. These may be different for each individual patient.”
What are the causes? How does someone develop borderline?
“That’s a good question. We don’t have a ready-made answer to it. In any case, it is an interaction of temperament and what someone experiences. Nature and nurture. For some the temperament factor is more important, for others the difficult living conditions. Often, but certainly not always, it is accompanied by a difficult childhood in very different areas. This could be emotional neglect, or emotional and/or sexual abuse. But someone who was severely bullied at school can also develop borderline. Recently we have been seeing that trauma more and more. That is why we must take bullying much more seriously and not make fun of it. It can leave deep wounds that are difficult to heal. Sometimes people also talk about the fact that there has been too little reflection in the parent-child relationship.”
Too little reflection? What does that mean?
“We partly form our identity by what we see in a care figure. We reflect that on ourselves, by doing it or not doing it. It is a support, but if there is too little reflection, then there is no support and things can go wrong.”
Does genetics have anything to do with it? Can a certain sensitivity to borderline problems be hereditary?
“That’s not my expertise. But I do think that you will fall back on nature and nurture anyway, even if there is a genetic factor. Does someone develop borderline because of their upbringing, or because there is an innate temperament? That is a chicken-and-egg discussion.”
You cite intense emotions that arise suddenly as one of the symptoms. That is somewhat reminiscent of bipolarity.
“It is indeed often confused with it. But bipolarity comes in more phases. People with borderline change their mood instantly. A small event, a miscommunication can trigger it. A sudden feeling of being abandoned or overlooked can be enough. But that is not enough to make the diagnosis. It is a very complex issue, as I said. It can really take weeks before a diagnosis is made.” (Read more below the photo)
What goes on in people with borderline?
“The psychoanalyst Otto Kernberg says that people with these problems, especially when experiencing interpersonal stress, view the world in black and white, or good and bad. I think there is a lot of truth in that. Their sense of identity fluctuates under stress. ‘Who are we, what are we doing here?’ That is the case with everyone to some extent, but with them it is much more so.”
“You can imagine it as being on a rollercoaster, where emotions often take over without you having any control over them. That gives a powerless and helpless feeling. That you need someone to help you.”
At what age does it usually manifest itself?
“Previously, the diagnosis was never made under the age of 18, because many of the symptoms are also characteristic of adolescents. That black and white thinking, quickly feeling set back, the feeling of not belonging. As adolescents, we all sometimes have impulsive ideas or thoughts and the emotions are somewhat more intense.”
“Science now believes that a diagnosis can indeed be made before the age of 18, although I do not completely agree with that. The thinking is that it is important to catch it earlier, from the point of view of prevention. But not much research has been done on it.”
If it can be confused, is there little difference between adolescent behavior and borderline?
“Gosh. Adolescent behavior means that you don’t take it so seriously. I think we really need to take the suffering of borderline patients seriously. I think it is also part of their suffering that they are not taken seriously, that they are often seen as difficult people who should act normal for once. While they really don’t want to do it themselves. We really shouldn’t ignore that.”
How can borderline patients be helped?
“The literature shows that the treatment of choice is real and intensive psychotherapy. Medication is possible, but only to support certain symptoms and psychotherapy. So it will not be cured by medication alone.”
Which medication are you talking about? Antidepressants?
“Yes. Because we haven’t talked about that yet: there is a lot of comorbidity – other conditions that are a direct result of it – with depression, for example. There is an overlap of at least 80 percent. Eight out of ten people with borderline will also show signs of depression. There is also a very large overlap with substance abuse, as well as with some anxiety disorder. These different diagnoses therefore often occur together.”
“I think part of the suffering of borderline patients is that they are not taken seriously, that they are often seen as difficult people who should act normal for once.”
Benedicte Lowyck
Professor at borderline-expert
“And that is precisely why it is important to properly recognize borderline. Because the treatment of depression in a borderline patient is not the same as in another patient. A specific approach is needed. Psychotherapy, that is. There are different forms of this, but the basic rule is that they must be intense enough and must be done by people who are specialized, who recognize the specific dynamics, but at the same time can tolerate them. Because don’t forget that such therapy is also quite intense for the therapist.”
What does such therapy look like?
“As I said, there are different types. We usually work with clinical psychotherapy. With group sessions and individual sessions, but living together is also an important element. This coexistence takes place under the guidance of sociotherapists – often nurses. In this way, the therapists see certain dynamics, certain patterns that can then be worked on in the psychotherapy itself.”
“In our therapy it is important that people gain insight into their problems, find out what the triggers are for them, and how they can deal with them differently. That they discover certain patterns themselves.”
Do those therapies work well?
(nods) “There are studies that show that after these intensive therapies, half of the patients no longer meet the criteria listed in the DSM-5, and that for a certain percentage of the remaining group the burden of suffering is much less is. Of course, this is not the case for everyone, but in the last twenty or thirty years we have seen good results being achieved with the various therapies. Before that time, the diagnosis of ‘borderline’ was rather pessimistic. They couldn’t really help those people. Fortunately, that has changed. There is realistic optimism, although it remains a heavy suffering for the people who are confronted with it and for those around them, in any case.”
“According to the latest figures, 1 to 2 percent of the Western population has borderline, and about 10 percent of all people in outpatient therapy. That is not a small group, and it may be an underestimate”
Benedicte Lowyck
Professor at borderline-expert
But is healing possible?
“We have investigated it ourselves – and are still doing so – and we can say that the effects achieved after therapy are still there for most patients five years later. With the condition that additional outpatient therapy is followed, about once or twice a week. Now, if people stop here, it is obvious that they will continue in therapy. But the results are very encouraging.”
Is borderline common? And is there a difference between men and women?
“According to the latest figures, 1 to 2 percent of the Western population has borderline, and about 10 percent of all people in outpatient therapy. That is not a small group, and it may be an underestimate.”
“It used to be assumed that about 75 percent of patients were women. But recent studies show that the difference is not that great, but that the comorbidity is different. Women have more self-harm and depression, while men have more alcohol and substance use. It is not immediately clear why this is the case. There could be a hormonal component involved, but there is little hard scientific evidence about this. Borderline is something that is present in all of us, to a greater or lesser extent. It is a very complex mix of factors that makes it a problem for some people.”
