Jennifer, aged 19, was referred to the mental health services by her family doctor following a series of crises in her family home. The problems became apparent some months earlier when Jennifer started to cut her arms with a knife. “Just small cuts,” she said, "nothing too deep.” Jennifer said she did not want to die, but wanted to “relieve tension.” Her family was very upset.
It was soon impossible to predict when Jennifer would have one of her increasingly frequent emotional crises. Sometimes she would become intensely upset following an argument with a friend, but on other occasions, she would abruptly decide that everyone hated her and start cutting her arms with no obvious trigger.
Jennifer’s behaviour became more impulsive over time. One night, she took an overdose of tablets and immediately regretted it, waking up her mother. Another time, she said that her friends were spying on her through her phone. When asked about this, Jennifer said she did not really believe it, “but it sometimes feels that way.” With great difficulty, Jennifer was persuaded to see her family doctor, who decided that Jennifer probably had a personality disorder.
Personality disorders are controversial conditions that can be difficult to define because they overlap to a significant extent with “normal” personality. But personality “disorders” are deeply ingrained and enduring behavior patterns that manifest as inflexible responses to a wide variety of social and personal situations. They are significant or extreme deviations from the way that average people in a given culture perceive, think, feel, and relate to others. For the most part, these behavior patterns date from childhood or adolescence and they cause significant distress and problems with social function and performance into adulthood.
An emotionally unstable personality disorder is a type of personality disorder that involves a tendency to act impulsively; emotional instability; diminished ability to plan ahead; and outbursts of anger, especially when impulsive acts are criticized. There are two sub-types of emotionally unstable personality disorder, “impulsive” and “borderline,” both of which are associated with impulsiveness and diminished self-control.
The “impulsive” sub-type is especially characterised by emotional instability and diminished impulse control. There are also outbursts of threatening or hostile behavior. The “borderline” sub-type involves emotional instability, often with disturbances to the person’s self-image, goals, and desires. There are also feelings of emptiness, a tendency towards involvement in intense, unstable relationships, recurrent emotional crises, fear of abandonment, and repeated threats or acts of self-harm.
In practice, many people with an emotionally unstable personality disorder display features of both sub-types. The condition is diagnosed more commonly in women than in men. It is five times more common in people who have a close relative with the disorder.
The causes of an emotionally unstable personality disorder are not known. Recent research shows that such a disorder is often (but not always) associated with parental neglect or emotional, physical, or sexual abuse. It can also be associated with subtle changes in brain areas concerned with mood regulation, including the amygdala, hippocampus, and orbitofrontal cortex.
Specific forms of behavioural therapy can prove very helpful in these disorders, especially dialectical behaviour therapy (DBT) which is an adaptation of the better-known cognitive-behavior therapy (CBT). CBT focuses on the use of cognitive strategies (related to thinking patterns and habits) and behavioural strategies (related to actions and behavioural habits), in an effort to re-frame negative thoughts, enhance coping strategies, reduce symptoms and promote recovery. Usually, the psychotherapist will meet the patient regularly (one-on-one or in a group) and point out errors or unhelpful thinking patterns that may deepen or prolong symptoms. Together, the patient and therapist identify ways to address these errors and habits, and improve symptoms.
DBT is somewhat similar to CBT but is now more commonly recommended for emotionally unstable personality disorders because it appears to address the person’s needs in a more realistic and enduring way. DBT involves attending group sessions, building skills such as mindfulness, and developing coping strategies other than deliberate self-harm for dealing with emotional instability. DBT is a challenging therapy but it can be highly effective. Other useful therapies include arts or creative therapies and mentalization-based therapy, which is a form of long-term psychotherapy focused on a person’s ability to recognize their own and others’ mental states.
The chief role of medication, if any, in personality disorders is the management of co-existing depression, anxiety disorder, mood instability, or other problems. Most treatment of personality disorders is delivered on an outpatient basis, but admission to psychiatric facilities can occur if symptoms are severe, the condition is treatment-resistant, or there is a risk of harm to self or others that can be diminished by admission (during a particular crisis).
Social support can be important for many people with a personality disorder, especially those with marked emotional instability; assistance with matters such as occupation and housing can help support overall stability.
In terms of prognosis, a majority of people with an emotionally unstable personality disorder attain greater stability in their 30s and 40s. Studies performed in psychiatry clinics indicate that after around 10 years, as many as half of all people diagnosed with an emotionally unstable personality disorder no longer fulfill criteria for the disorder, although they may still show some signs of emotional instability from time to time.
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