Borderline Personality Disorder, Case vignette (2)

A CASE OF Borderline Personality Disorder

By: THEODORE MILLON et al.

Notes:

(1) Numbers mark aspects of the case most consistent with DSM criteria as follow, and do not necessarily indicate that the case “meets” diagnostic criteria in this respect.

(2) Patient's name has been changed in respect to confidentiality, and names mentioned are not of a real existent person.

Case of Georgia

Elizabeth, age 21, presented at the university counseling center seeking professional help related to problems at home. Her mother, Georgia, has a long history of psychological problems, and is now going through a difficult period.

Georgia believes that she has never been appreciated by anyone, including her own mother, husband, children, and employers. Georgia was the middle child in a family of moderate means. The second daughter of three children, she was always compared unfavorably to her older sister, an excellent student and now a prominent attorney. In contrast, Georgia was an average student, although her teachers felt she could do much better. In fact, Georgia was the “black sheep” of the family, who never lived up to her mother’s expectations. She recalls her mother saying over and over again during their many arguments, “I should have abandoned you when I realized what a lousy kid you were.”

Georgia married Elizabeth’s father, Harold, whom she apparently adored, the summer after their high school graduation. In the early years, Harold did everything for Georgia, but somehow, it was never right or never enough, and her attitude toward him changed. Harold, a solid individual by Elizabeth’s account, sees Georgia as a troubled soul who “can’t get her life together.” Elizabeth and her younger brother avoid their mother as much as possible. “Sometimes she shifts, like between blaming you one minute and smothering you with love the next,” Elizabeth says. “She can’t make up her mind whether to love you or hate you. It’s ridiculous.” (2)

Georgia’s erratic behavior has had a similar outcome both socially and vocationally. (6) She makes a good first impression, but her numerous part-time jobs always end the same way, with Georgia seizing on some minor problem and voicing an angry indignance over the way she was treated. (8)  Social contacts had the same course. “She alienated everyone in our neighborhood,” Elizabeth stated. “Some people she’d piss off, others felt smothered by her neediness, and some got both. Over and over again, she’d make friends, then throw a tantrum, and call them and cuss them. Whenever she’s excluded from community activities, she gets mad because she swears they’re talking about how to keep her out.” (9)

Presently, Georgia is being seen twice a week for treatment of depression. According to Elizabeth, her history includes threats of suicide, though she has never actually gone further. (5)  Currently, she is very angry that Harold refuses to use part of the children’s college fund to finance a month-long stay at a Caribbean resort, and says she will no longer speak to him. (8)  In response, Harold is simply exasperated. (4)

DSM-IV Criteria

A pervasive 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. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
(3) identity disturbance: markedly and persistently unstable self-image 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 eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
(6) affective instability due to a marked reactivity of mood (e.g., intense 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.

References

(1) Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

(2)Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

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