Imagine being part of a family where everyone walks on eggshells all the time.
Visualise a home-life punctuated by the histrionic outbursts of an adult child or sibling who is given to rollercoaster mood swings, verbal aggression and even self-harming, and who is seemingly unable to sustain employment or form lasting relationships.
Add to that a manipulative tendency to play people off each other.
Sound unbearable?
Yet, these are among a group of symptoms which add up to a mental health problem which, it seems, is relatively common. Experts say up to 6 per cent of people have borderline personality disorder (BPD), a statistic which means that families all over Ireland are struggling to cope with the chaos caused by this condition on both the loved one and on themselves.
“The central component of this is unstable interpersonal relationships, unstable employment relationships, manipulative behaviour, disruptive behaviour, over-use of drink or drugs and self-injurious behaviour. Their lives are in chaos,” observes Ted Dinan, professor of psychiatry at UCC.
A person with BPD may also frequently form very intense emotional new relationships, which will generally not last for any length of time, he explains, adding that break-up may precipitate a crisis which can potentially be followed by self-harm.
Although it’s believed that early childhood trauma – death of a parent, sexual abuse or domestic violence – is linked to the condition, he says, he adds that he has encountered people from “very stable backgrounds” who have “significant BPD”.
Crisis
Whatever its cause, the impact on a family can be significant: a family with a member who has borderline personality disorder is constantly in crisis and experiencing constant histrionics.
“You get tranquility for short periods of time and then there’s a blow-up,” says Prof Dinan, adding that daily life is rarely if ever, calm, relaxed or easy-going. “The family is constantly walking on eggshells because they never know when this individual will explode over the most trivial issue. That’s extremely difficult.”
The condition, which experts say, is usually not diagnosed until a person is in their late teens, brings with it "core problems" in terms of a large amount of emotional dysregulation, according to Dr Cian Denihan, consultant psychiatrist at St John Of God Hospital, who adds that although physical violence is uncommon, BPD patients tend to experience very unstable mood swings and their interpersonal relationships often tend to be chaotic, featuring "lots of conflict".
Elizabeth (not her real name), a highly educated professional in her mid-40s, has been diagnosed with borderline personality disorder, emotional dysregulation and depression. “It started when I was 17 or 18 and has caused a lot of difficulty in my life,” she recalls. “I have attempted suicide seven or eight times, I’ve had prolonged hospital stays, and I’ve experienced feelings of despair.
“I have self-harmed many times, and suffered from anorexia, engaged in alcohol and drug abuse; anything, really, to block out what I was feeling. Sometimes I feel great and the world is going well and other times my feelings of despair, self-loathing, shame and anger at myself are overwhelming.
“I feel I’m putting my family and friends through hell as a result of the things I do. I do things which are utterly destructive. I can get very angry at myself to the point where I can’t cope.”
Her mother, Catherine, recalls that “we’ve had terrible things happen, but we stay calm. Over the years we’ve learned to deal with it better. On one occasion we picked her up off the street after she had taken something and brought her to hospital. She has a big issue with depression and self-loathing.
“She attempted suicide for the first time in second year of college. Out of the blue we got a call from a friend to say she had overdosed – that was the start of her suicide attempts of which she had eight in the last 20 years.
“Each time she recovered [from a suicide attempt], she’d promise us that it would never happen again, but we were always afraid it might, and we never relaxed. The last time she tried to commit suicide she ended up on life support; she could have died. It’s been a rollercoaster over the years but somehow we’ve kept on top of it.
“We’ve gone through a lot as parents but we’re a very calm and grounded couple and we have a long and strong marriage which is a blessing. I worry that she has no partner. We worry all the time. We’re very tuned in to her. Depression is a huge part of what she is and she cannot help it. It can come on without warning. I could talk to her in the morning and she would be fine.
Survive
“However, by the afternoon it could all have changed, and she could be deeply depressed. I talk to her four or five times a day and always last thing at night so that I know that she will survive the night.”
Put it this way, explains Dr Patrick Ryan, clinical psychologist and director of the doctoral programme in clinical psychology at the University of Limerick: "From a psychological perspective, BPD is all about disorder. It's about disorganisation in the people who have the symptoms. They're a mix of everything you can think of," he says. "They are depressed, anxious, angry; they love you, they hate you; you are the best person in the world and the worst in the world. At the same time they have a sense of being nothing. It's difficult to know who you are sitting in front of today."
Most of us have features that are core and stable elements of our personalities he explains, but he adds, someone with BPD can, quite literally, be a hundred different things in an hour: “They find it very difficult to regulate things inside themselves – for example their internal regulation of their mood, how they think about things and how they perceive and interpret threat is all compromised.”
Outside the home, Prof Dinan explains, an individual with the condition is often unlikely to be able to hold down a job for any length of time, and will often blame others when things don’t work out: “They are either fired or they will resign. This tends to be a pattern where someone has multiple jobs within a short period of time.
“The person can be very clever and intelligent but they are not able to sustain employment,” he explains.
It is a tremendously stressful condition to live with, he observes, adding that some people with BPD can also be extremely manipulative: “They will try to manipulate other people in the family so that there is continuous tension in the family, and manipulation of other people within the family.”
If people refuse to go along with the manipulation there can be a major crisis. “Someone may take an overdose or they can be very verbally aggressive or physically aggressive towards parents or siblings if they’re not getting their own way.”
Deep depression
Because someone with BPD may not take responsibility for his or her actions, he adds, it can often take a major crisis, such as deep depression or an incident of self-harm to bring them to the attention of a doctor.
BPD is “the most common, most complex and most severely impactful of personality disorders,” observes Consultant Psychiatrist at St John Of God Hospital, Dr Cian Denihan, who warns that the disorder creates “a huge amount of suffering for people with the condition, and for their families”.
“There is a very high overlap with mood and personality disorders and there may be complications with abuse of alcohol or substances or eating-disordered behaviour.
“Intimate relationships and relationships with friends and family can be very turbulent and there tends to be limited ability to solve interpersonal problems. Therefore ordinary conflicts or interpersonal differences tend to escalate very swiftly into feelings of rejection, abandonment or being criticised.
“Things change so quickly, and they are so highly sensitive it is like living on a rollercoaster. It can cause a huge amount of anxiety and concern and relationships can be quite polarised.
“There can also be a lot of anger at the impact of their behaviour at home,” he says, adding that St John of God Hospital runs both an out-patient group for patients, which is based around dialectical behaviour therapy (see below) and a separate out-patient education and support group for families and concerned others. Currently both groups are subsidised by the hospital and funded by patients and family, but, says Dr Denihan, long term it is hoped that the programme will receive the support of the health insurance industry so that fees would be recoverable.
Treating the conditions
Dialectical behaviour therapy (DBT) is a treatment developed for people with issues around self-harm urges, suicidal thoughts or attempts.
People with a long history of these difficulties may have been given a diagnosis of borderline personality disorder (BPD) or emotionally unstable personality disorder.
The benefits of this form of therapy, which was originally developed in the United States, has been proven by more than 20 years of international research.
In Ireland, the Mental Health Services in Cork is co-ordinating the National DBT Implementation Project which has been running since 2013 and has, to date, trained 23 teams around the country in the therapy. "We have taken a therapy developed in the United States which works, and translated it into the Irish context," explains Daniel Flynn, senior clinical psychologist and area principal psychology manager, Cork Mental Health Service.
“The idea is that if someone is experiencing emotional dysregulation we try to intervene to teach them new skills to regulate harmful patterns of behaviour which can compound underlying emotional problems,” says Flynn. “It is a talk therapy.”
“There are three strands to the therapy,” says Flynn, who is clinical lead on the National Dialectical Behaviour Therapy (DBT) Project.
Clients attend individual, one-on-one therapy sessions with a DBT therapist.
They also join a skills group, where they participate in a mindful-based approach to learning specific skills.
These include distress tolerance skills which, he explains, are essentially crisis survival skills, the skills of emotional regulation, which teach the client to label what they’re feeling and “turn the volume down on high emotions and handle their emotions”, and interpersonal effectiveness skills which help them in terms of learning how to maintain relationships and build closeness.
The third element in the DBT process is phone coaching, where the therapist is available to the client between sessions to coach them in using these skills effectively.
“Research has found that this therapy is effective in reducing symptoms such as depression, suicidal ideation, self-harm and intensity of self-harm, as well as reducing attendances at emergency departments and hospital admissions,” says Flynn, adding that the DBT project in Cork also runs a programme to support families who live with someone with BPD or emotional dysregulation.
