Borderline Personality Disorder
Across the Life Span
Melissa Hunt, PhD
SUMMARY. Borderline personality disorder is characterized by af-
fective dysregulation, intense, unstable interpersonal relationships,
impulsivity and unstable identity. It overlaps considerably with both
PTSD and bipolar spectrum disorders. Research on true late-life BPD is
limited, but suggests that some of the core features of BPD including in-
terpersonal difficulties, unstable affect and anger remain relatively un-
changed, while impulsivity and identity disturbance decline or change
their mode of expression in late life. Diagnosis of BPD in late life re-
quires flexible application of the standard diagnostic criteria as well as a
thorough longitudinal history. The etiology of BPD is best explained as
a combination of genetic, neurobiological vulnerability combined with
childhood trauma, abuse or neglect that leads to dysregulated emotions,
distorted cognitions, social skills deficits, and few adaptive coping strat-
egies. Treatment options include pharmacotherapy (especially mood
stabilizers, SSRIs and atypical antipsychotics) and psychotherapeutic
interventions that focus on distress tolerance, affective regulation,
changing distorted beliefs, and introducing new social and relationship
problem-solving skills (especially Dialectical Behavior Therapy and
Schema Focused Cognitive Therapy). In late-life care environments,
Address correspondence to: Melissa Hunt, Dept. of Psychology, University of Pennsyl-
vania, 3720 Walnut St., Philadelphia, PA 19104-6241 (E-mail: [e-mail]).
[Haworth co-indexing entry note]:  Borderline Personality Disorder Across the Life Span. Hunt, Me-
lissa. Co-published simultaneously in Journal of Women & Aging (The Haworth Press, Inc.) Vol. 19, No. 1/2,
2007, pp. 173-191; and: Mental Health Issues of Older Women: A Comprehensive Review for Health Care
Professionals (ed: Victor J. Malatesta) The Haworth Press, Inc., 2007, pp. 173-191. Single or multiple copies
of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH, 9:00
a.m. - 5:00 p.m. (EST). E-mail address: [e-mail]].
Available online at http://jwa.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J074v19n01_11 173
174 MENTAL HEALTH ISSUES OF OLDER WOMEN
such as nursing homes and other residential facilities, staff need to be
empowered to set appropriate limits on problematic behavior while
maintaining empathy and validating the painful affect patients often ex-
perience. doi:10.1300/J074v19n01_11 [Article copies available for a fee from
The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:
Website:
© 2007 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Borderline, personality disorder, women, aging, character
INTRODUCTION
Borderline personality disorder is the quintessential personality disor-
der. Starting in adolescence and continuing more or less unchanged at
least until the early to mid-40s, its hallmark symptoms include intense
and highly unstable affect, intense and highly unstable relationships, poor
impulse control, and an overwhelming, painful sense of emptiness. Some
patients with BPD engage in self-mutilatory or other non-fatal self-harm-
ing behaviors. Some make frequent suicide attempts. Indeed, the 10 to 15
year mortality rate (secondary to suicide) for individuals with BPD is ap-
proximately 10% (Paris, 2002). There is considerable debate about the
course of BPD in later life, with most research suggesting that while
many of the core features of BPD persist into late life, there are also sig-
nificant changes in the presentation of the disorder (Rosowsky & Gurian,
1991; Trappler & Backfield, 2001).
Prevalence
Epidemiological data suggest that the prevalence of BPD in the gen-
eral community is approximately 1.8% (Swartz, Blazer, George &
Winfield, 1990). Widiger and Weissman (1991) in a comprehensive re-
view reported that various studies have estimated a prevalence range
from .2 to 2.8%. They also noted that rates of BPD are significantly
higher among psychiatric inpatients (15%), while BPD cases comprise
50% of personality disorders among psychiatric inpatients. There is a
considerable sex difference, with women outnumbering men three to one.
DIAGNOSTIC CRITERIA
The gold standard in diagnostic criteria for mental disorders is the
DSM-IV, the Diagnostic and Statistical Manual for Mental Disorders, 4th
Melissa Hunt 175
Edition (American Psychiatric Association, 1994). The specific criteria
for BPD are as follows: BPD is characterized in the DSM-IV as  a perva-
sive pattern of instability of interpersonal relationships, self-image, and
affects, and marked impulsivity beginning by early adulthood and present
in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment (not includ-
ing suicidal or self-mutilating behavior).
2. A pattern of unstable and intense interpersonal relationships char-
acterized by alternating between extremes of idealization and de-
valuation.
3. Identity disturbance: markedly and persistently unstable self-im-
age or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging
(e.g., spending, sex, substance abuse, reckless driving, binge eat-
ing) (but not including suicidal or self-mutilating behavior).
5. Recurrent suicidal behavior, gestures, threats or self-mutilating
behavior.
6. Affective instability due to a marked reactivity of mood (e.g., in-
tense episodic dysphoria, irritability, or anxiety usually lasting a
few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g.,
frequent displays of temper, constant anger, recurrent physical
fights).
9. Transient, stress-related paranoid ideation or severe dissociative
symptoms (p. 654).
The most widely-used structured diagnostic interview for BPD is the
Revised Diagnostic Interview for Borderlines (DIB-R) (Zanarini,
Gunderson, Frankenburg & Chauncey, 1989). The DIB-R distinguishes
four main categories of symptoms including interpersonal difficulties,
affective disturbance, cognitive disturbance and impulsivity.
DIFFERENTIAL DIAGNOSIS AND COMORBIDITY
Interestingly, the features of BPD overlap considerably with both
PTSD and Bipolar spectrum disorders. Not surprisingly, there are high
comorbidity rates between BPD and these disorders, and differential di-
agnosis can sometimes be difficult.
176 MENTAL HEALTH ISSUES OF OLDER WOMEN
PTSD. PTSD has several core features that overlap with BPD, in-
cluding affective instability (particularly anger/irritability), numb or
empty feelings and interpersonal dysfunction (Zlotnick, Johnson, Yen
et al., 2003). Moreover, there is considerable comorbidity between the
two diagnoses. Zanarini, Frankenburg, Dubo et al. (1998) found
comorbid PTSD in 56% of a sample of patients with BPD. At the same
time, Shea, Zlotnick and Weisberg (1999) found that 68% of PTSD pa-
tients they examined also met diagnostic criteria for BPD.
This has led to considerable debate about the conceptual differences
between PTSD and BPD (see Gunderson & Sabo, 1993a; Kudler, 1993;
Gunderson & Sabo, 1993b). Gunderson and Sabo (1993a) point out that
many BPD patients experienced significant trauma in their early lives
and are therefore quite vulnerable to developing PTSD. They point out
the enduring effects that trauma (especially early trauma) can have on
the formation of personality traits. Zlotnick, Johnson, Yen et al. (2003)
examined the clinical features, level of impairment and trauma histories
of women with BPD versus women with both BPD and PTSD. They
found that co-morbid PTSD increased both hospitalizations and general
dysfunction. They found that most of their subjects (89%) had experi-
enced some type of abuse from a primary caretaker before the age of 13.
For the comorbid BPD and PTSD group, there were higher rates of sex-
ual, physical, verbal and emotional abuse than in the BPD alone group.
The important point to keep in mind for those working clinically with
BPD is that trauma history is often highly relevant, and that it can be
helpful both to the clinician and the patient to conceptualize certain
aspects of BPD as related to trauma survival and chronic PTSD.
Affective and Bipolar Spectrum Disorders. There is also considerable
overlap between the core features of BPD and a number of affective dis-
orders, including major depressive disorder, atypical depression, bipo-
lar disorder, and various bipolar spectrum disorders including bipolar
II and cyclothymia. Akiskal (1985) was one of the first to point out
that the affective symptoms of BPD were central features and probably
represented a core temperamental vulnerability. He and his colleagues
also suggested that BPD could best be conceptualized as falling within
the broad spectrum of bipolar disorders (Akiskal, 1981; Akiskal,
Hirschfield, & Yerevanian, 1983).
These similarities can make differential diagnosis difficult. Smith,
Muir and Blackwood (2005) examined 87 patients who met criteria for
bipolar disorder, bipolar spectrum disorder or major depressive disor-
der. While none of the patients in the study met diagnostic criteria for
Melissa Hunt 177
BPD, patients with bipolar disorder endorsed significantly higher num-
bers of borderline symptoms than did patients with unipolar depression.
Bellino, Patria, Paradiso et al. (2005) found that severity of BPD pa-
thology in depressed individuals was positively correlated with the oc-
currence of mood disorders in first-degree relatives. They concluded
that patients with co-morbid MDD and BPD showed a stronger familial
link with mood disorders than is shown by depressed patients with other
Axis II disorders, strongly suggesting that BPD may share at least some
of the genetic basis of mood disorders.
Moreover, there is considerable overlap between BPD and atypical
depression. Atypical depression is defined by mood reactivity, rejection
sensitivity, increased appetite and hypersomnia. Many people diag-
nosed with atypical depression go on to experience an episode of
hypomania and are ultimately diagnosed with bipolar II (Akiskal,
Walker, Puzantian et al., 1983; Perugi, Akiskal, Lattanzi et al., 1998).
Perugi, Toni, Travierso and Akiskal (2003) found that this same cluster
of atypical symptoms was common among depressed borderline pa-
tients. Perugi and Akiskal (2002) argued persuasively that BPD belongs
within a broad clinical group that includes atypical depression and bipo-
lar disorder, and that all three stem, in part, from an underlying cyclo-
thymic temperament, or biological affective lability. Smith, Muir and
Blackwood (2004) reviewed recent work in neurobiology on the phe-
nomenology of these disorders, and on the efficacy of mood stabilizers
in the management of BPD symptoms, and strongly supported the util-
ity of conceptualizing BPD as a bipolar spectrum disorder. They point
out that  since borderline patients can be so challenging to care for, it
may be that a reframing of the disorder as belonging to the broad clinical
spectrum of bipolar disorders holds benefits for patients and clinicians
alike (page 133).
On the other hand, it is also important to note that BPD remains a sep-
arate disorder that imposes unique burdens on the patient, and unique
challenges to the clinician. Thinking of it as a bipolar spectrum disorder
is therapeutically useful, but does not address the significant skills defi-
cits, the trauma history, the unstable interpersonal relationships or the
intensity of continual crisis management that is often required early in
treatment. McGill (2004), while acknowledging the considerable evi-
dence in favor of classing BPD with the bipolar disorders, cautioned
that BPD itself is still a valid diagnosis, and that careful consideration of
the patient s longitudinal history is crucial to establishing the correct
diagnosis.
178 MENTAL HEALTH ISSUES OF OLDER WOMEN
DIAGNOSIS IN LATE LIFE
There is a striking lack of relevant research on BPD in true late life,
with most studies examining patients in their 40s and 50s. For example,
in one study of older patients with BPD, the oldest patient was only 52
(Stevenson, Meares & Comerford, 2003). Nevertheless, some conclu-
sions can be drawn about the course of BPD into later life. In one widely
cited study, Reich, Nduaguba and Yates (1988) found that the trajectory
of Cluster B personality disorder traits followed a reverse J shaped
curve, with the mean number of traits declining as subjects aged into
their 40s and 50s, but then increasing again slightly as subjects aged
past 60.
Other authors have noted that there is a change in the pattern of symp-
toms as BPD patients age. In particular, they appear to become less im-
pulsive over time, although it may be that behavioral expression of
impulsivity simply changes. Stevenson, Meares and Comerford (2003)
found that age significantly predicted declines in the impulsivity cate-
gory on the DIB-R, but did not predict declines in affective or relation-
ship disturbance. There was a trend toward reduction in cognitive
disturbance as well, but it was not significant using their stringent
criteria.
Paris and Zweig-Frank (2001) conducted a 27-year follow-up of a
cohort of BPD patients they had originally assessed in the 1980s. The
mean age of their sample was 51. In contrast to the above study, they
found that there were no significant changes in impulsivity, while there
were large and highly significant decreases in relationship difficulties.
Their most striking finding was that only 8% of patients continued to
meet criteria for BPD using the DIB-R. They interpreted these findings
as suggestive that BPD patients may improve in later middle-age. Oth-
ers take a less sanguine view, however, and express concern that diag-
nostic criteria may simply be insensitive to BPD in late life.
Rosowsky and Gurian (1991), for example, examined the records of
eight elderly patients identified as BPD by clinicians experienced with
geriatric populations who had had extensive contact with the patients.
In this study, the patients were genuinely older adults, ranging in age
from 64 to 85. The researchers applied both the DIB-R and the
DSM-III-R criteria to the identified individuals. Not a single one was
identified as having BPD by the DIB-R and only two were identified by
the DSM-III-R. They concluded that the DIB-R and the DSM criteria
were invalid with this specific aged population. Careful analysis of their
data revealed that certain domains of the DIB-R and certain DSM crite-
Melissa Hunt 179
ria were sensitive to the sample. In particular, they found that difficul-
ties with interpersonal relationships and social adaptation, affective
dysregulation and anger were clearly impaired relative to age-matched,
but non-BPD controls. In contrast, they found that neither the domains
of impulsivity nor the criteria regarding identity disturbance were
sensitive enough to discriminate BPD patients in late life.
Agronin and Maletta (2000) addressed the general lack of research
on personality disorders in late life, and pointed to a number of reasons
that such research is difficult to conduct, including the relatively recent
development of diagnostic criteria and the necessity of reviewing the
entire life history of the patient. They also pointed to a number of spe-
cific difficulties in assessing BPD in late life. First, a pattern of unstable
and intense interpersonal relationships may be hard to assess in late life,
when the attenuation of social relationships and losses due to death may
make it difficult to ascertain the degree to which it has been a chronic
and pervasive problem. Second, they pointed out that identity distur-
bance is less relevant in late life, and that it is unclear exactly how it
would present, since defining life choices regarding sexual orientation,
marriage/family and career are no longer relevant. Finally, they note, as
above, that levels of impulsivity appear to decline in late life. However,
they point out that the mode of expression of self-harming behaviors
may be quite different in late life, and that the examples provided in the
DSM-IV may not be applicable to geriatric populations. They suggest
that better examples might include things like non-compliance with
medical treatments, polypharmacy, and disordered eating.
ETIOLOGY
Genetic Vulnerability and Neurobiological Findings. There is con-
siderable evidence that BPD is heritable. One twin study of personality
disorders (Torgersen, Lygren, Oien et al., 2000) found concordance
rates of 7% in dizygotic twins, but 35% in monozygotic twins, suggest-
ing a substantial genetic component. They calculated the heritability of
BPD at 69%. Skodol, Siever, Livesley et al. (2002) suggested that BPD
may be the result of several different clusters of heritable traits, the most
important of which is probably emotional dysregulation. They noted
that the central psychobiological domains of BPD include impulsive ag-
gression, which is associated with reduced serotonergic activity, and af-
fective instability, which is associated with increased responsiveness of
the cholinergic systems.
180 MENTAL HEALTH ISSUES OF OLDER WOMEN
Both structural and functional neuroimaging studies have also sug-
gested a clear biological etiology to BPD. A number of studies have
pointed to dysregulation of the frontal and limbic brain regions, which
together are responsible broadly for both impulse control and affective
regulation. For example, Schmahl and colleagues (Schmahl, Elzinga,
Vermetten et al., 2003; Schmahl, Vermetten, Elzinga et al., 2004) have
found evidence that the anterior cingulate cortex fails to activate fully in
women with BPD when they are exposed to stressful memories of aban-
donment or childhood abuse. Other studies have found evidence of
structural and metabolic changes in the limbic system, such as reduced
volume of the hippocampus and amygdala (Driessen, Herrmann, Stahl
et al., 2000) along with increased metabolic activity in the amygdala un-
der emotional arousal conditions (Donegan, Sanislow, Blumberg et al.,
2003). There is also evidence of stress hormone (cortisol) induced
changes in the brain systems of women with BPD that are very similar
to those seen in chronic PTSD (Rinne, de Kloet, Wouters et al., 2002)
and strongly suggest chronic hyperresponsiveness of the hypotha-
lamic-pituitary-adrenal (HPA) axis.
Of course, while genetic studies certainly point unequivocally to eti-
ology, the other biological findings cited above could simply be de-
scriptive of the symptoms experienced by patients with BPD in the here
and now. That is, such biological changes may be concomitant with the
affective instability BPD patients experience, rather than causal. Know-
ing that there are considerable biological and neurological correlates of
the borderline syndrome is helpful, however, when it comes to
maintaining empathy and planning treatment.
Childhood Experience and Trauma
Of much more clear-cut etiological relevance to BPD is childhood
experience and, in particular, childhood trauma, abuse and neglect.
Zanarini and colleagues (Zanarini, Williams, Lewis et al., 1997;
Zanarini, Yong, Frankenburg et al., 2002) found that of 358 patients
with BPD, 91% reported having been abused and 92% reported having
been neglected before the age of 18. Moreover, BPD patients (relative
to other personality disorders) were significantly more likely to have
been emotionally and physically abused by a caretaker and sexually
abused by a non-caretaker. They were also significantly more likely to
have had a caretaker withdraw from them emotionally, or treat them
inconsistently. Finally, the severity of reported childhood sexual
abuse was correlated with the severity of borderline pathology and
Melissa Hunt 181
psychosocial impairment in adulthood. McLean and Gallop (2003)
found that both BPD and complex PTSD were far more likely in women
reporting early-onset sexual abuse than late-onset sexual abuse. Good-
man and Yehuda (2002) traced how childhood trauma could impact
brain morphology, serotonergic responsivity and HPA axis reactivity in
ways that are consistent with the various symptom clusters of BPD, in-
cluding impulsive aggression, dissociation, identity disturbance and af-
fective instability. In a recent review, Bradley, Jenei and Westen (2005)
note that a substantial body of research has confirmed that there is a link
between BPD and childhood abuse and neglect. They also found that
while childhood sexual abuse contributed to the prediction of BPD
symptoms over and above family environment, other family factors
such as instability partially mediated that effect.
One potential mediating mechanism between childhood abuse/ne-
glect and adult BPD is that early experience alters one s worldview and
basic beliefs about the self. Butler, Brown, Beck and Grisham (2002)
found evidence that BPD patients hold numerous dysfunctional beliefs
reflecting themes of dependency, helplessness, distrust, fears of rejec-
tion/abandonment and fear of losing emotional control. Giesen-Bloo
and Arntz (2005) also found that BPD patients hold inflexible and
maladaptive beliefs. They tend to view the world as malevolent, and
themselves as unworthy and incapable.
Graybar and Boutilier (2002) sounded a cautionary note, however,
and pointed out that childhood abuse is neither necessary nor sufficient
to cause BPD. Many victims of childhood abuse do not grow up to suf-
fer from BPD, and a substantial minority of BPD patients report no sig-
nificant childhood abuse. They point to other, non-traumatic pathways,
including temperamental vulnerability and neurological deficits.
In summary, it seems that the best way to conceptualize the etiology
of BPD is that a powerful diathesis (a temperament highly prone to af-
fective lability, sometimes clearly verging on bipolar spectrum disor-
ders) combines with stressors such as childhood trauma (which can also
result in chronic, complex PTSD). The trauma is neither necessary nor
sufficient, but does have implications for severity in a dose-response re-
lationship the more severe and long-lasting the trauma, the more severe
the BPD pathology is likely to be. Together, these two major etiological
factors result in changes at a number of levels, including the biological,
cognitive, experiential and behavioral. In the end, BPD patients are left
with wildly dysregulated emotions, distorted cognitions, severe social
skills deficits, and few coping strategies they can count on.
182 MENTAL HEALTH ISSUES OF OLDER WOMEN
EFFECTIVE TREATMENTS
Affective Instability
The Role of Medication. Several classes of psychotropic medica-
tion have proven to be quite useful in managing some of the more dis-
tressing symptoms of BPD (see Mohan, 2002 for a review). Mood
stabilizers/anticonvulsants have proved to reduce affective lability as
well as behavioral impulsivity. Randomized controlled trials have
supported the use of lithium (Links, 1990), carbamazapine/tegretol
(Cowdry & Gardner, 1988), divalproex sodium/depakote (Hollander,
Allen, Lopez et al., 2001) and lamotrigine/lamictal (Pinto & Akiskal,
1998). Antidepressants, especially the SSRIs and the MAOIs, are also
useful, especially in reducing symptoms related to anger/irritability,
and not just in cases where there are significant depressive symptoms
(e.g., Coccaro & Kavoussi, 1997; Cowdry & Gardner, 1988). In severe
cases, there is good reason to consider the use of antipsychotic medica-
tions, especially some of the newer generation medications (e.g.,
Olanzapine/Zyprexa) that have more tolerable side-effect profiles and
secondary mood stabilizing attributes (e.g., Schulz, Camlin, Berry &
Jesberger, 1999).
The main difficulty with pharmacotherapy for patients with BPD is
that they may be highly resistant to taking psychiatric medication. They
may be loathe to  depend on a substance, and may reject any positive
effects as  false because they feel so discordant with their normal state.
Careful explanation of the mechanism of action of various medications
can help, as can pointing out that there is no  black market for Zoloft or
Tegretol because they are not  mood enhancing drugs. That is, they
only work when there is an underlying problem that needs to be fixed.
Distress Tolerance and Affect Regulatory Skills. While pharma-
cotherapy can go a long way toward relieving some of the more acute
affective distress and impulsivity, psychotherapeutic interventions are
still necessary. BPD patients often have very little tolerance for distress
(Linehan, 1993) and few normative skills for regulating affective expe-
rience. Unfortunately, the strategies they turn to (e.g., dissociation,
self-mutilation, binge eating, or substance use) are powerful anodynes
in the short term. Going for a walk, taking a bath, or drawing a picture
simply doesn t give the same immediate and powerful relief. Therefore,
it is crucial to help BPD patients understand the tradeoff between
short-term relief and long-term exacerbation of the very symptoms they
are trying to escape. Most BPD patients quickly grasp the long-term
Melissa Hunt 183
costs of such behaviors. They know that they end up feeling worse.
They simply can t think of alternatives in the moment.
Relationship Instability
Using the Therapeutic Relationship. The core component of a correc-
tive therapeutic experience for patients with BPD is probably validation
(Linehan, 1993). This one strategy allows the caregiver to maintain em-
pathy and helps the BPD patient develop a trusting, constructive rela-
tionship with the caregiver. It is certainly true that the behavior of
people with BPD is often highly maladaptive, and often brings about
exactly the social rejection and abandonment by caretakers that they
most fear. However, it is also the case that they are genuinely in enor-
mous pain, and are truly doing the best they can with the skill set they
have to cope with life and manage their emotions and their social rela-
tionships. Validating their pain that is, acknowledging the legitimacy
of their feelings and empathizing with their distress, confusion, frustra-
tion and even rage, often goes a long way towards calming them down.
One does not have to agree that their emotional response is proportional
or even appropriate to the events in question, but it is crucial to ac-
knowledge their experience and to try to understand how they inter-
preted the events. This is the first necessary step in helping them to
recognize and change their distorted beliefs and maladaptive behaviors.
Caretakers must remember that patients with BPD often came from
genuinely neglectful or abusive origins, and that this has sensitized
them to the least hint of maltreatment.
One useful strategy is to warn BPD patients up front that caregivers
are human, and will, therefore, make mistakes. It is important that the
patient agrees to let the caregiver know when they feel angry or
wounded, so that the caregiver can apologize for any missteps and the
patient and caregiver can work together to try to avoid similar incidents
from reoccurring.
Addressing Social Skills Deficits. When BPD patients  act-up it is
often because they have misinterpreted some aspect of the social envi-
ronment in a way that is consistent with a core maladaptive belief
(Newman, 1998). Caregivers should try to explore and understand the
perspective of the patient that is, how they perceived and interpreted a
series of events in order to make sense of the patient s maladaptive be-
havior. Caregivers should also actively model adaptive social problem-
solving.
184 MENTAL HEALTH ISSUES OF OLDER WOMEN
Self-Harming and Suicidality
One of the most disturbing and frightening aspects of borderline per-
sonality disorder for most clinicians is the management of self-injurious
behavior, including non-suicidal self-injury (e.g., self-mutilation such
as  cutting and burning) and suicide attempts. While there is evidence
that these behaviors decline substantially in later life (e.g., Stevenson,
Meares & Comerford, 2003), there is also reason to think that they may
simply be expressed in other, more subtle ways (e.g., Agronin &
Maletta, 2000). These behaviors are easily interpreted by care providers
and family as  manipulative acting out and are a primary reason many
therapists are reluctant to work with patients with BPD. Indeed,
para-suicidal behavior is the single best predictor of death by suicide
(Gunnell & Frankel, 1994).
Brown, Comtois and Linehan (2002) examined the self-reported rea-
sons for non-suicidal self-injury in a sample of 75 women with BPD.
They found that BPD patients engage in self-injury primarily to manage
out-of-control affect. That is, self-harming behavior provided a powerful
distraction from painful emotions, but also allowed the individual to ex-
press emotions, especially anger, in a powerful, but private way and
could be used to normalize emotional experience. It was also reported to
be a way to punish the self for perceived failings. Stanley and Brodsky
(2005) conceptualize self-injurious behavior primarily as a means to
self-regulation. Paris (2005) also found that self-mutilation is most likely
to be a means of regulating dysphoric affect and coping with dissociative
states, although it can also be used as a way to communicate distress.
Ironically, self-mutilatory behavior is often assumed to be manipula-
tive a way of punishing or expressing anger towards those the BPD pa-
tient perceives as having injured them, but this is quite inconsistent with
the actual clinical phenomenon. Most self-injurious behavior is carried
out in secret, inflicted on hidden parts of the body, and rarely disclosed
to a caregiver unless the patient is directly confronted. BPD patients as-
sume, quite rightly, that if they reveal self-injurious behavior, it will
quickly become a target of treatment, and most are reluctant to give up
this highly efficacious (though clearly maladaptive and counter-thera-
peutic) strategy for regulating their own distress.
PSYCHOTHERAPY OUTCOME STUDIES
Very few randomized controlled trials have assessed the efficacy of
therapeutic interventions for BPD. Dialectical behavior therapy (DBT),
Melissa Hunt 185
a variant of cognitive behavioral therapy, has the most empirical sup-
port, with seven well-controlled trials (see Lieb, Zanarini, Schmahl et
al., 2004). DBT is a highly comprehensive treatment program that in-
cludes both individual and group therapy, skills training, and weekly
meetings of therapeutic staff for support and consultation (Lieb et al.,
2004; Linehan, 1993). An open trial of cognitive therapy (CT) in which
patients received weekly individual therapy (and therapists participated
in monthly group consultation and support) also showed promising re-
sults including significant and clinically important decreases on measures
of suicide ideation, hopelessness, depression, number of borderline
symptoms and dysfunctional beliefs at termination and 18-month assess-
ment interviews (Brown, Newman, Charlesworth et al., 2004; Layden,
Newman, Freeman & Morse, 1993). Finally, a very recent RCT com-
paring schema focused cognitive therapy to psychodynamic therapy
found the CT intervention to be significantly more effective (Arntz,
2005).
BPD IN NURSING HOMES AND GERIATRIC SERVICES
While comprehensive treatment programs for BPD are probably the
ideal, they may be quite unrealistic for late-life patients who are resi-
dents of nursing homes or are otherwise receiving geriatric care.
Rosowksy and Gurian (1992) point out that the symptoms of BPD in el-
derly patients have a considerable impact on systems of care for geriatric
patients. For example, they note that food refusal, non-compliance and
the active sabotage of medical care may be geriatric variants of
self-harming behaviors. Moreover, disturbed interpersonal relation-
ships can wreak havoc in a nursing home setting. They note that elderly
patients with BPD may still show the typical vacillation between
overvaluing and demeaning care providers, including nursing staff,
occupational therapists and social workers. Affective instability and
mismanaged anger in the patient can result in insulting behavior, exces-
sive litigiousness and conflicts with authority. This can lead to consid-
erable resentment and frustration on the part of caregivers, who may
feel trapped by basic ethical and legal constraints into complying with
outrageous requests and excessive demands made by such patients.
Moreover, BPD patients can often cause  splits or conflict between
caregivers, who may find themselves either defending or vilifying the
patient. It is important in such cases to view the conflict as stemming
186 MENTAL HEALTH ISSUES OF OLDER WOMEN
from the BPD pathology, and to ensure frequent case consultation
among caregivers to minimize such friction.
Trappler and Backfield (2001) tracked the impact of three different
BPD patients who were older than 50 on an inpatient psychiatric unit.
They note that the actual losses associated with aging (of significant
others or of physical health) are likely to trigger decompensation in el-
derly patients with BPD. They raise the concern that frailty, loss, and
fear of abandonment may be inadvertently reinforced in institutional
care settings, resulting in heightened somatization and protracted hospi-
tal stays. Fear of loss and fear of abandonment are developmentally nor-
mative for many geriatric patients but such normative concerns are
grossly exaggerated in the BPD patient, and may lead to frantic, de-
manding and antagonistic behavior with caregivers, which is easily mis-
interpreted as manipulative, hostile or cruel. Caregivers must be free to
set appropriate limits, but should also recognize the genuine terror that
an elderly BPD patient may be experiencing.
Himelick and Walsh (2002) also reviewed how BPD pathology mani-
fests itself in long-term care settings, and pointed to the serious problems
BPD patients often experience in relating to nursing and therapeutic staff.
They make excellent recommendations for how social workers can de-
velop intervention strategies and serve as intermediaries between the
BPD patient and the staff, helping to minimize the common polarization
or  splitting that often occurs in such cases. They emphasize the need
for validating the BPD patients physical and emotional pain and needs,
while simultaneously encouraging caregiving staff to set appropriate
limits and boundaries with such patients. They also recommend that
specific behavioral contingencies be established that will encourage ap-
propriate self-care, and will discourage the patient from sabotaging
medical interventions. For example, a patient might be reinforced for
eating, or leaving an IV in place, with extra time with a favorite staff
member. Attention and support then become contingent on appropriate,
adaptive behavior, rather than the patient receiving extra care in re-
sponse to maladaptive behavior. Educating the caregiving staff about
the goals and utility of such plans is crucial, lest they view the plan as
 rewarding or  caving in to a problematic patient.
In the end, the interventions with geriatric BPD patients have a simi-
lar goal as the interventions with younger patients. Caregivers must val-
idate the very real losses, traumas and emotional pain the patient is
experiencing, as well as their (often well-founded) fear of abandon-
ment. They must then find ways to help the patient understand that more
adaptive, consistent behavior will actually result in less distress in the
Melissa Hunt 187
long run as caregivers are better able to meet their needs. The losses of
old age are legion in the best of circumstances. When they are magni-
fied by the BPD patients history of loss, trauma and neglect, by their
vulnerability to affective disorder, and by a genuine lack of adaptive
coping skills, it is no surprise that such patients would engage in desper-
ate measures to manage their pain and get their needs met. It is crucial
that caregivers maintain their empathy for these fragile patients, while
still demanding and setting the stage for adaptive change.
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