Many of the illness. The majority of studies around

Many of the symptoms of patients with
borderline personality disorder can be explained in relation to other
co-existing symptoms. For example, suicidality and self-harm may be due to poor
impulse control (and the impulsivity itself may stem from an inability to think
logically in emotionally charged situations), while instability in
interpersonal relationships may be due to emotional dysregulation, fear of
abandonment, or a host of other symptoms. Despite this, in terms of treatment
it is useful to understand the deeper causes of the illness.

            The
majority of studies around the etiology of BPD emphasise the importance of
early attachment relationships. Indeed, most of the issues in BPD revolve around
emotional regulation and the internalised representations of self and others,
healthy forms of which are thought to evolve only in the context of familial
stability and nurturing relationships with primary caregivers. This is further
evidenced by the fact that many patients with BPD describe themselves as
feeling like “a child trapped in an adult’s body” – many symptoms of the
disorder are related to normal thinking patterns in children (e.g. black and
white thinking, separation anxiety and difficulty regulation emotions), so from
this we can assume that something in early childhood prevented borderline
patients from outgrowing these thinking patterns.

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            Two
symptoms which are key in the psychopathology of BPD are emotional instability
and fear of abandonment. Adler & Buie (1979) theorised that the emotional
instability seen in BPD was due to a deficit in what they labelled ‘evocative
object constancy’ (essentially the inability to self-soothe by drawing on
internalised memories of soothing others), and that this deficit was often the
direct result of childhood experiences with unavailable or abusive caregivers:
not only would these children not have been taught this skill, but they would
also have a lack of images of soothing caregivers to draw on when distressed.

This in turn can contribute to feelings of extreme loneliness, as patients who
are unable to draw on internalised images may rely on the actual presence of
significant others to manage their emotions. Of course, the fear of abandonment
seen in borderline patients may also be due to a history of abandonment – after
all, BPD has been described as a complex form of PTSD, and a meta-analytic
study in 1993 found that 20-40% of patients with the disorder had experienced
traumatic separations from at least one of their primary caregivers.