Borderline Personality Disorder (BPD)

Diagnostic criteria: instability, impulsivity and fear of abandonment.

Borderline Personality Disorder is defined by a pervasive pattern of instability in relationships, self-image and affect, accompanied by marked impulsivity.

The central driver of this suffering is a frantic fear of abandonment, whether real or imagined.

A delay of a few minutes in an appointment can trigger absolute panic or disproportionate anger, interpreted as total rejection. At least five symptoms are required for diagnosis.

These include intense and chaotic interpersonal relationships, alternating between extremes of idealization and deva luation.

Identity disturbance is marked; the individual may drastically change goals, values or career path in a matter of days.

Impulsivity is potentially self-injurious (excessive spending, risky sex, binge eating).

Suicidal behaviors, attempts or threats and self-mutilation are frequent.

In addition, they suffer from reactive affective instability (intense episodic dysphoria), chronic feelings of emptiness and inappropriate anger or difficulty in controlling it.

Defense mechanisms: Splitting.

A distinctive defense mechanism in BPD is splitting. Faced with the inability to integrate the positive and negative aspects of people or situations into a coherent whole, the individual perceives the world in black and white.

People are classified as "perfect saviors" or "evil traitors". There is no middle ground.

This manifests itself, for example, when a patient treats one member of the therapeutic team with absolute adoration, considering him the only competent one, while fiercely denigrating another colleague.

This polarization can change suddenly; yesterday's "hero" becomes today's "villain" at the slightest frustration or perceived rejection.

This mechanism not only fragments the patient's personal relationships, but can also divide professional teams in clinical settings if not properly managed.

Treatment of Choice: Dialectical Behavioral Therapy (DBT)

The most empirically supported intervention for BPD is Dialectical Behavioral Therapy (DBT), developed by Marsha Linehan.

This approach combines cognitive-behavioral techniques with mindfulness and acceptance practices.

It is based on a dialectical vision: the therapist must balance the unconditional acceptance of the patient as he or she is, with the imperative need for change.

DBT is structured in modules that teach specific skills that the patient often lacks: emotional regulation (learning to manage intense emotions without acting impulsively), distress tolerance (surviving crises without making the situation worse), interpersonal effectiveness (asking for what is needed and saying no) and mindfulness.

Unlike purely verbal therapies, DBT is very practical and often includes telephone coaching between sessions to generalize the skills to the real environment.

Summary

Characterized by pervasive instability in relationships and self-image, driven by a frantic fear of abandonment. They experience extreme mood swings and impulsivity often leading to self-injurious behaviors.

They use "splitting" as a defense mechanism, perceiving people in black and white. This polarization prevents them from integrating virtues and defects, causing sudden shifts between absolute idealization and fierce deva luation.

Dialectical Behavioral Therapy is the treatment of choice. It combines acceptance and change, teaching specific skills such as emotional regulation and discomfort tolerance to manage crises without resorting to destructive impulsivity.