BPD A lifelong disorder?

Dr. Marina Averbach and Luis TESZKIEWICZ. Thanks to the media, anyone interested can know today that many diagnoses, such as addictions, psychoses, bipolar disorders can improve with treatment but at least with the methods at our disposal at present, no disorders are curable, that is, those suffering and their families have to learn to live with the disorder. Many patients diagnosed with BPD are wondering if they are in the same case. In fact, in many cases of BPD and a variable time after treatment, we are forced to change the presumptive diagnosis, and not always because the diagnosis was wrong. It is not uncommon that, once solved the most pressing symptoms and reduced anxiety that go with them, other paintings emerge underlying, masked until then by the storm symptomatic. This circumstance is confirmed by the fact that BPD is a disorder of youth, which usually improves with age and, in general, does not extend beyond the 3 rd or 4 th decade of life. To show what we mean by resort to a couple of clinical examples. For reasons of discretion does not give real names or precise data, so you will need the confidence of the reader to accept our conclusions.

Joseph has 24 years, study or work and spends the day watching TV mired in their own dreams. At age 15 he had a crisis diagnosed as toxic psychosis for cannabis. Since then he has suffered feelings of emptiness and dissatisfaction of those who intended to escape imagining unrealistic plans that even strives to implement. Reacts to frustration with excessive consumption of various drugs, emotional outbursts, bouts of extreme anger and violent behavior that, in cycles, causing police intervention and psychiatric admissions. When calm is discharged and the cycle begins again. Parents attribute most of the difficulties of Joseph to drug, so it has undergone various detoxification has no results. Your symptoms match those of BPD: unstable relationships, impulsivity, emotional instability, aggressive response to frustration, anger inappropriately, identity disorders, chronic feelings of emptiness, failure of planning. All therapies attempted so far have been unsuccessful and it does not seem to be very promising, since he seems unwilling to cooperate, is only forced by parents, of course, are desperate. Joseph is considered different, but not sick, "my parents are sick, do not let me live my life?.

The blame for their lack of achievement is always the other, preferably from their parents. Certain features of his personality (chatter, accelerated speech, expression through metaphors not always understood by the interlocutor, megalomania) lead us to change your medication, using the lithium, a mood stabilizer especially useful in Bipolar Disorders. At the same time, a family interview is an agreement Jose back to live with their parents, they will not be forced to enter treatment or detoxification hospital and he refuses to stop pressing for some time to study or work give space to his therapy and he himself was responsible for their situation., José return undertakes to try to facilitate coexistence, meet certain minimum standards, stop using drugs and undergo regular poison control to demonstrate compliance with part of the agreement (something which has refused so far). The change is dramatic. Joseph shows less aggressive and more stable mood. Increase your ability to reflect, recognize the unreality of their fantasies and lack of any plan to carry out, realize that you have lived in a cloud, start looking for a training that suits both their preferences as to the reality.

Clear that this awareness is not without pain: emerging anguish, sadness and guilt that so far not been revealed. Mary, 38, has a long career as a psychiatric patient psicoterpéutica, in some cases with recognized professional and proven ability. He was diagnosed years ago as well as TLP and presented. And indeed met, and even in excess, the DSM diagnostic criteria (7 out of 5 required): 1 - unstable relationships with alternating idealization and desvalorización.2 º - Impulsiveness. 3 - emotional instability with alternating joy, sadness and irritability. 4 - Ira inappropriate and often leads to arguments and fights. 5 - mistaken identity disorders perception of itself and its deseos.6 º - chronic feelings of emptiness. 7 - Efforts to avoid it, as titanic as ineffective.).

His disorder is diagnosed as BPD as well as the criteria of the IEC (6 on 3 required for diagnosis): 1-Impulsivity. 2 -? Minimum unstable. 3-Disability planning. Response 4-aggressive, or self-injurious, to the frustration. 5-Impaired self-image and desires. 6-so intense and unstable relationships) Your most manifest symptoms, or at least that she offers as such, impulsivity and sexual promiscuity, for which she describes as fox and other equally derogatory epithets. The first thing I note is that the query is not a confessional and we will not judge morally their sexual behavior. Then the compulsive character emerges and unsatisfactory sexual life: no love for it (or what looks bad because it does not get it) or pleasure is given to men who denigrate more momentum by desire, can achieve orgasm But once the relationship invade guilt, emptiness and anxiety. We then decided to attend the pathological character, symptomatic of a sexuality that, beyond its intensity or frequency, makes you unhappy, without any moralizing intent. And we ask her to do the same, and to stop using bad words to refer to itself.

In a relatively short time learns not always respond to the desire of the other, to say "no? when he believes that the relationship will not find it satisfactory, which will make it happy, especially with men who do not respect, that does not recognize it as a whole human being. Failure to respond to their expectation of moral conviction to interrupt a short help of acting out and self-punishment (guilt) that leads fatally to a new acting and a new fault, repeating the cycle. Restricted their sexual activity, not for moral reasons but because one must try to avoid that which is not good, rediscovered by herself, Mary begins to question his ambivalent idealization of male Iberian and therapy opens up to other problems: the tendency to acting, intense emotional ambivalence, claim compensation for the injustices suffered in childhood. Then ceases to meet the minimum diagnostic criteria required by the canon and emerges Histrionic Personality Disorder, hidden until then by stormy symptoms. Personally I think even when it met the diagnostic criteria for BPD also met with a much earlier diagnosis of classical psychiatry (so forgotten and so useful many times): the hysterical neurosis, which seems to be in worse press between patients and families the supposedly more severe BPD, because they often confuse hysteria with manipulation or with an insult.

If the diagnosis of BPD at the time helped Mary to name her discomfort and stop being a weirdo, the questioning of that diagnosis has allowed him to stop seeing itself as a case, as a patient to begin to be considered as a person with psychological difficulties, the first step to taking responsibility for your attitude in life and the problems it causes this attitude. Continued treatment with antidepressants and psychotherapy dynamics. Psychotherapy is not a rose garden or work miracles. Joseph and Mary continue to struggle in their therapies and their lives with their illnesses, their symptoms, their problems and, from time to time, suffer a relapse. But situations have lost some of its drama, and this because they begin to glimpse their disorders are not a life sentence and begin to sense an exit. Also for the family of Joseph has decreased anxiety. Maria's family finds it difficult to recognize the progress made by it, remain tied to an image already formed, may arrive in time to accompany her, or you may have to stand alone on this path. Time will tell.

More and more cases come to consultations with symptoms that, in principle, consistent with BPD. I think because of the reality we live, with a growing demand for individual adaptability constantly tests our internal resources, more and more will come. In the informative booklet ACAI-TPL were characterized, among other things, as "people, mostly young, suffering from a kind of personal chaos, which sometimes leads them to risk your life?. "They try to combat their anxiety and fear that awareness of this situation causes them, clinging to a relationship" quasi-symbolic? with any person, group, sect, and also with drugs, sex, gambling, etc...? "Those who are" hooked? to drugs will stop drug centers, but "quietly? I confess to taking the drug therapist to try to escape his anguish and personal chaos?. But this is not what happens to all or most young people are hooked on drugs? Are drugs and alcohol are not always a failed attempt to self-medication? , Is the need to always have to hand an object to escape from the anguish?.

This clinical finding has led some psychiatrists Ego American Psicology to postulate that all addiction is a borderline (BPD). Moreover, the excellent description of ACAI-TLP you can find on their website do not describe an increasingly large segment of Western youth and as a result of globalization, worldwide?. As Foucault says, every period of history has developed its own mental illness. Will not the TLP, and generally narcissistic disorders, by complex social and psychological causes a bad characteristic time in which we live? I do not want to deny this, on the contrary, the existence of individual diseases and diagnostics that allow grouping and guide us, provided that these diagnoses are not watertight compartments in which to lock up our patients and we are always open to changes occur during the treatment. The diagnoses are not absolute truths but tools for our work. Consequently, the category by which we evaluate is its usefulness. What is a diagnosis or a presumptive diagnosis? To guide practitioners in choosing the most appropriate medication and in the direction of healing therapy.

But the TLP, unlike bipolar disorder for example, lacks, at least for the moment, a specific medication (antidepressants, anxiolytics, mood stabilizers and even certain antipsychotics may be used depending on symptoms). Have also been proposed several specific psychotherapeutic techniques for these disorders but, as the psychiatrist and psychoanalyst Harold Searles, who was the first to propose (in 1965) a specific therapy for BPD, other patients suffering from different disorders may also benefit of these techniques. Why do I serve the patients and their families? To name what happens to them, to find a cause to order the situation to reduce the guilt of the subject, now designated as sick, suffering from a disease recognized by science, to recognize him as the victim of a mental disorder and not just perpetrator family, your partner, your friends, to generate the expectation once found the disease, also find a cure. But it can also have undesirable effects: desreponsabilizar the subject, no longer feels responsible for their actions because the disorder is to blame, to confine the patient in his illness, knowing his thoughts, preferences, desires, demands, they cease to be yours to be considered effects of his illness.

The diagnosis at hand can also have another utility, you might call institutional: for patients and families gather together and reclaim the resources pledged by the state psychiatric reform but which still lack: Group Therapy, Day Hospitals , Accommodation for when in a crisis situation it is necessary to temporarily detach the patient and his family, Specific Units Brief Income not force them to share those revenues with psychotic patients, which can be counterproductive because of the lability symptomatic of BPD. In fact, since the Andalusian parliament is drafting a bill to BPD that can be useful. Conclusions: Many patients arrive at the consultation and diagnosed or self diagnosed as BPD. Most, not all cases are serious about the serious suffering of the patient and resulting in his family, but are often very different. In many cases, though not always, this diagnosis is correct. But not all diagnoses are compartmentalized and final. The TLP, with time and proper treatment can be forwarded, reducing suffering and leading to the emergence of another underlying disorder.

On the other hand, psychiatrists and psychotherapists do not address cases or diseases or disorders, but individual human beings, complex, not reducible to any diagnosis. Every case is unique because every subject is unique and unrepeatable. We intend to listen to this person, this particular human being, your discomfort, on the premise that it is an exceptional case because it is a particular individual, which we can not cover with any diagnosis, we believe most diagnostic categories.