600 CHAPTER 13
In relationships with those closest to me, the “good” and “bad” assessments could
alternate wildly, sometimes from one hour to the next. The unrealistic expectations of
perfection that came with the good-guy pedestal were destined to be unfulfi lled, which
led to disappointment and sense of betrayal.
(2004, p. 88)
The highly fl uid and impulsive behaviors that are part of borderline personality
disorder arise, in part, because of the patient’s strong responses to emotional stim-
uli. For example, if a patient with borderline personality disorder has to wait for
someone who is late for an appointment, the patient often cannot regulate the ensu-
ing powerful feelings of anger, anxiety, or despair, which can last for days. More-
over, the person with this personality disorder is extremely sensitive to any hint of
being abandoned, which also can cause strong emotions that are then diffi cult to
bring under control.
When not in the throes of intense emotions, people with borderline personality
disorder may feel chronically empty, lonely, and isolated (Klonsky, 2008). When
feeling empty, they may harm themselves in some nonlethal way—such as super-
fi cial cutting of skin—in order to feel “something”; such behavior has been called
parasuicidal rather than suicidal because the intention is not to commit suicide,
but rather to gain relief from feeling emotionally numb. The parasuicidal behav-
ior usually occurs when the person is in a dissociated state, often after he or she
has felt rejected or abandoned (Livesley, 2001). More worrying to clinicians, fam-
ily members, and friends is when the self-harming behavior is a suicide attempt.
In fact, almost 10% of people with borderline personality disorder die by suicide
(Linehan & Heard, 1999; Paris, 1993).
Table 13.15 provides additional facts about borderline personality disorder. The
table notes that this disorder is more commonly diagnosed in women than in men,
but this difference may be due to diagnostic bias on the part of clinicians: Given
identical cases and symptoms, clinicians are more likely to diagnose women with
borderline personality disorder than men; clinicians may see women with symp-
toms of borderline personality disorder as more ill than their male counterparts
(Becker & Lamb, 1994; Strain, 2003).Table 13.14 • DSM-IV-TR Diagnostic Criteria for
Borderline Personality DisorderA 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 fi ve (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: This impulsivity does 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 [poor
mood], 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 diffi culty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fi ghts).
(9) transient, stress-related paranoid ideation or severe dissociative symptoms.
Note: The criteria for borderline personality disorder involves four domains: Interpersonal (in green); cognitive (in
orange); behavior (in purple); and emotional (in blue).
Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,
Text Revision, Fourth Edition, (Copyright 2000) American Psychiatric Association.frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-
mutilating behavior covered in Criterion 5.
a pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
identity disturbance: markedly and persistently unstable self-image or sense of self.
impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Note: This impulsivity does not include suicidal
or self-mutilating behavior covered in Criterion 5.
recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria [poor
mood], irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
chronic feelings of emptiness.
inappropriate, intense anger or diffi culty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fi ghts).
transient, stress-related paranoid ideation or severe dissociative symptoms.People with borderline personality disorder may
engage in parasuicidal behaviors, such as cutting
their arms, to help regulate their emotions. These
scars on a 50-year-old woman are a result of such
parasuicidal behavior. Self-harming behavior
may also occur in an attempt to commit suicide.Lauren Shear/Photo Researchers