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Author Topic: Borderline Personality Disorder and Couple Dysfunctions - Sébastien Bouch  (Read 1511 times)
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« on: October 01, 2009, 11:39:34 AM »

Borderline Personality Disorder and Couple Dysfunctions

Sébastien Bouchard, MPS, and Stéphane Sabourin, PhD

Current Psychiatry Reports 2009, 11:55–62 Current Medicine Group LLC ISSN 1523-3812  
www.springerlink.com/content/x588530017721153/fulltext.pdf[/color]

The central characteristics of borderline personality disorder (BPD) are bound to be associated with the development and maintenance of couple dysfunction. Although seven of the nine diagnostic criteria of BPD in the DSM-IV-TR refer directly to interpersonal functioning, very few empiric studies have addressed the exact nature of the relationship between BPD and couple functioning. This article examines recent studies describing couple outcomes—union formation and durability, partner choice, relationship satisfaction, intimate violence, attachment security, and sexual functioning—associated with BPD. The relationship between couple dynamics (including partner personality characteristics) and BPD symptomatology is probably bidirectional or reciprocal. The review concludes with an exploration of diagnostic and treatment implications.

Introduction

In discussing the research agenda for DSM-V Axis II, some authors argue that future personality disorder criteria should explicitly refer to the ability to establish and maintain fulfilling, intimate, long-term relationships [1]. Couple quality and stability are associated with a diverse array of positive educational, occupational, social, and personal outcomes [2]. Thus, the proposition that the inability to pursue relational life tasks in adulthood is a defining feature of personality disorders appears promising [1]. In fact, the challenge to develop a durable, loving relationship is a daunting task for most people suffering from personality disorders [3••], particularly borderline personality disorder (BPD). Surprisingly, the research evidence supporting this hypothesis is sparse. This article reviews recent studies examining whether BPD is related to a clinically significant alteration of couple functioning. Specifically, we examine empiric data pertaining to six aspects of couple dysfunctions in BPD: 1) union formation rates and stability, 2) partner selection processes and partner psychosocial profile, 3) relationship satisfaction, 4) intimate violence, 5) attachment security, and 6) sexual functioning. Before assessing the research literature, we briefl y present relevant clinical data.
 
In clinically driven analyses of BPD, relationship dysfunctions are discussed from many perspectives. First, from a descriptive viewpoint, the central characteristics of BPD—uncontrolled anger, impulsivity, cycles of idealization and devaluation of self and others, hypersensitivity to rejection, and self-destructive behaviors—form a syndrome that is bound to manifest itself mainly in close relationships and represent an intrinsic aspect of this syndrome [4,5]. Second, BPD is a severe mental disorder characterized by high rejection sensitivity [6]. Thus, relationship difficulties can intensify or stabilize the expression of borderline symptoms. Inversely, couple satisfaction is also presented as a buffer—or as a protective factor— against the worsening of BPD symptoms. Paris [7,8] has reported a compelling series of case studies underlining the role of couple issues in the evolution of BPD. Third, when studying the natural course of BPD, couple events have been examined as a specific category of psychosocial outcomes, positive or negative, of the disorder. The remission of BPD symptoms potentially allows these patients to work through important couple life tasks (eg, choosing an adequate partner, strengthening engagement, solving daily problems, learning to tolerate individual differences in marriage, overcoming sexual inhibitions).

Finally, a perusal of recently developed manuals for the individual treatment of BPD—dialectical [9], psychoanalytic [10,11], and schema-focused [12]—clearly indicates that the association between BPD and couple functioning is pervasive but complex. Likewise, couple therapy practitioners taking diverse approaches increasingly report that BPD is overrepresented in distressed couples who seek help [4,13••,14]. Fruzzetti and Fruzzetti [4] estimate that by using subthreshold criteria of BPD (at least three criteria met), close to 50% of distressed couples seeking treatment have at least one member with borderline personality traits or the full syndrome of BPD. From a strictly clinical perspective, the BPD couple functioning equation is judged to be signifi cant; it is probably bidirectional and needs to take into account several vantage points involving elements of couple functioning relevant for scrutinizing BPD’s etiology, essential nature, and natural course.

Dimensions of Couple Functioning Associated With BPD

Union formation and durability

A first generation of research showed that BPD is associated with a lower probability of being married [15,16], greater number of break-ups in significant relationships [17], shorter friendship duration, and absence of an intimate partner or confidante [18]. In a 15-year follow-up study involving an extensive series of BPD patients (n = 502), Stone [19] reported marriage rates below national rates in the United States at the time (52% for women, 29% for men). More recently, in their study on hospitalized BPD patients observed for 7 years, Links and Stockwell [20] found that borderline patients married at the same rate as the comparison group of former inpatients. However, they noted that patients remaining single were younger, more impulsive, and had more dissociative episodes than patients in an intimate relationship. Finally, in a 27-year follow-up of a cohort of 100 BPD patients diagnosed using the DSM-III criteria, Paris and Zweig-Frank [21] indicated that 67% of their participants had been married, whereas the rate of divorce reached 36%; nevertheless, only 42% of these BPD patients were presently involved in a stable relationship.

In their important study, Whisman et al. [3••] excluded BPD diagnoses but used a large sample size (n = 43,093 adult respondents) against which the occurrence, timing, and disruptions of marital unions in BPD eventually could be compared in future investigations. Their results showed that personality disorders were associated with decreased probability of marriage, higher rates of early marriage, and elevated risk of marital disruption. No comparable data exist with a representative sample of individuals diagnosed with BPD. However, an examination of recent naturalistic studies that analyzed the clinical course of BPD and randomized clinical trials looking at the efficacy of various treatments for BPD shows three interesting trends (Table 1)—two substantive and the other methodologic [22•,23–26].

First, a significant percentage of patients (30% to 45%) with BPD are involved in an intimate couple relationship. Second, the results of two large-scale, prospective studies on the longitudinal course and outcome of BPD [27,28] provide relevant data on the prognosis for couple stability in BPD. In the McLean Study of Adult Development (MSAD), the probability of BPD patients in remission being married or living with a partner increased from 15.4% to 38% over a 6-year period. For nonremitted BPD patients, this percentage remained stable at 15%, and the difference with remitted patients was signifi cant. In the Children in the Community Study [28], after controlling for Axis I disorders in adolescence, elevated borderline symptoms in adolescents predicted lower partner involvement 20 years later. We recently conducted a small-scale study of 35 couples in which the woman was diagnosed with BPD [22•]. Mean relationship duration was almost 6 years (SD = 8.8; range, 2 months–38 years). Most of these couples reported a chronic pattern of episodic relationship instability characterized by intermittent break-ups and reunions approximately once every 6.5 months. In addition, 28.6% of clinical couples reported having broken up definitively before the end of the study, which lasted about 18 months. Finally, in a longitudinal study of male batterers presenting with high borderline symptomatology, the rate of relationship instability (separation or divorce) reached 75% over a 3-year period [29].

Third, from a methodologic perspective, there is a striking lack of descriptive and relevant couple data in research reports investigating BPD (eg, union status and duration). Overall, recent studies suggest that couple formation and duration are problematic processes in BPD patients. However, the relationship picture is not as negative as clinicians tend to expect it to be. In a signifi cant proportion of cases, once formed and after a period of adaptation and increased conflicts, couples in which one member suffers from BPD can reach a sort of “instable stability.” These preliminary results are interesting, but to gather a more complete picture of relationship stability in BPD, future investigations should routinely include more systematic and descriptive measures of current and past cohabitating and marital unions.

Partner choice and partner well-being

Concern has grown among clinicians and researchers that among BPD patients, partner choice may have a significant effect on symptom intensity and treatment prognosis [30,31]. In this context, the success of long-term couple relationships depends partially on the personality of the partners whom BPD patients select [30]. If empiric evidence confi rms this hypothesis, the systematic assessment of a partner’s personality and a couple’s dynamics could become an important addition to diagnostic protocols used with BPD patients.

The National Institute of Mental Health states that people with BPD generally have poor judgment in choosing partners [32]. Although evidence for assortative mating exists in many psychiatric disorders, including alcoholism, drug use, schizophrenia, antisocial disorder, and affective disorders [33,34], specific data for assortative mating in individuals diagnosed with BPD are scarce. However, some indirect evidence exists.

First, dysregulation of aggression is a hallmark of BPD, and externalizing problems has been shown to infl uence a partner’s choice among adolescents and adults. For example, aggressive girls are more likely to select aggressive men as intimate partners [35], and adult romantic pairs display substantial homophily of aggression and delinquency [36]. Second, as similarity in personality-related domains is generally related to marital quality and duration [36,37], one would expect to find higher rates of personality disorders in intimate partners of people with BPD, especially in well-established couples.

To our knowledge, only one study supports this contention [22•]. Using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, these researchers found a 55.9% rate of personality disorder in intimate partners of women with BPD, whereas the expected rate of personality disorder in the general population is 9% to 15.7% [37]. At this early stage, it is difficult to determine whether this high proportion of potentially dysfunctional pairings refl ects poor partner choice, attraction by shared developmental failures [38], or simply a limitation in the availability of adequate partners.

The well-being of spouses or family members living with BPD patients also has gained attention recently. Scheirs and Bok [39] administered the Symptom Check List (SCL-90) to 64 spouses and parents of BPD patients. The results showed a degree of psychological distress comparable with what is normally observed in families of schizophrenic, depressive, or post-traumatic stress disorder patients. This high distress was as elevated in parents as it was in intimate partners. Our own data on the romantic partners of patients with BPD suggest that their psychological distress is twice as high as what is found in men from nondistressed couples [22•]. Hoffman and colleagues [40] showed the following: 1) family members and partners generally had little knowledge about BPD; 2) the more knowledge they had, the more depressed, burdened, hostile, and psychologically distressed they were; 3) a high degree of agreement exists between patients and those close to them on the personality traits of the BPD patient; and 4) BPD patients and those close to them disagreed on the personality traits of family members (or partners) who were perceived by BPD patients as evidencing a higher level of neuroticism and lower levels of extraversion and openness.

Recent studies reviewed here suggest the validity of some clinical concerns about the quality of partner choice and the maladaptive processes at work in these families. The hypothesis that caregivers (spouses or parents) present significant mental health impairments that may be conceptualized as causes or consequences of BPD has received preliminary support. However, the research basis on which this hypothesis rests should be strengthened. Innovative psychoeducational programs for families with an individual diagnosed with BPD have the potential to shed light on this question and to provide relevant data [41]. There were also some methodologic weaknesses in these studies: small samples, samples mixing partner with relatives, and insufficient information to compare the psychosocial profi les of partners and parents with population norms.

Relationship satisfaction

Poor relationship satisfaction and high relationship distress are expected in couples in which one member suffers from BPD. The results of early studies suggested that an Axis II diagnosis significantly decreased relationship satisfaction [42,43]. This negative effect was more important for couples in which one partner suffered from a personality disorder than for couples in which one partner suffered from an Axis I disorder.

To our knowledge, three studies have examined BPD and couple quality in clinical samples using a categorical DSM diagnosis. In the MSAD [27], self-reported relationship quality (being in a good or in an emotionally sustaining, close relationship involving at least weekly contact without elements of abuse or neglect) was lower in BPD patients (33.5%, n = 290) than in patients with other personality disorders (46.3%, n = 72). In addition, over a 6-year period, the evolution of relationship quality was more positive for remitted than nonremitted BPD patients. More specifi cally, the percentage of remitted patients who felt they were in a good relationship rose from 37.6% (n = 202) to 63% (n = 200), whereas for nonremitted BPD, this percentage increased from 26% (n = 88) to 43.8% (n = 64).

Hill et al. [44] compared romantic relationship dysfunction in patients with BPD (n = 46) with those with avoidant personality disorder (n = 27) and individuals with no personality disorder (n = 25). The main findings revealed that compared with other patient groups, BPD was related to more romantic relationship dysfunction. BPD patients also evidenced elevated avoidant romantic relationship. To our knowledge, only one study has directly assessed couple satisfaction in BPD patients and their partners. Bouchard et al. [22•] first showed the absence of within-partner difference on couple distress in these unions. In addition, both partners of these BPD couples reported lowered dyadic satisfaction than community couples. These differences were statistically strong (d = 0.80 for the difference between men, d = 1.26 for women). When comparing these satisfaction scores with population norms [45], the results indicated that 49% of women with BPD and 40% of their male partners were clinically distressed. This is an important finding because rates of couple distress in population samples vary from 20% to 30% [46,47].

Borderline symptoms and traits were related to relationship quality or adjustment in three recent studies. First, in a report based on a subsample of older adolescents from the Children in the Community Study (n = 200) observed over a 10-year period (from age 17 to 27 years), Chen et al. [48] observed that after controlling for Axis I disorders and other symptoms of personality disorders, self-reported borderline symptoms were associated with sustained elevations in partner confl ict throug
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« Reply #1 on: October 19, 2009, 04:47:57 AM »

Hi

Good article but too academic.

Can someone good at writing "precise" to shorten it with highlighting the key points so that the reader can read it more with ease?

Tks

Peter
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« Reply #2 on: October 19, 2009, 10:21:43 AM »

Yea, I agree with Peter Chu. This article is too focused on percentages and hypotheses, and even if I was a professional counselor I would find it hard to follow. 
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« Reply #3 on: October 19, 2009, 10:13:39 PM »

a high prevalence of personality pathology probably exists among the romantic partners of women with BPD suggests that merely educating the partner about BPD and how to behave with such a person may fail to address some clinically important behavioral patterns that could be part of the non-BPD partner. As many authors believe ... .an effective approach to treating women with BPD should strive to integrate, when possible, a couple approach, as the intimate partner can be viewed as a vicarious victim or an unrecognized contributor to the manifestations of BPD.

I found the above to be the most insightful.

It is important to make the distinction that the recommendation is not the "Couples Counseling" or "Marriage Counseling", rather a more specialized therapeutic plan developed after individual analysis of the non's specific contribution (or victimization) in the BPD symptomatology.

The other important fact I gleaned was that there is a disproportionate number of BPD diagnoses when only a few traits were present.  When only a few traits are present then perhaps it is not a "mental illness" but simply a person who behaves badly... .many on this board have asked this question:  Is this mental sickness or is my SO just immature/evil/uncaring/unethical/... .etc. etc.

Minus the statistics, the article precisely reflects what we see on this board repeatedly... .for many of us that is a validation of our own thoughts on the issue of BPD.

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« Reply #4 on: October 21, 2009, 07:02:58 PM »

I had to do a review of the literature for my masters in psychology a couple of months ago and chose to write a paper on the stigma of BPD and its subsequent affect on research and treatment especially as it relates to interpersonal dynamics in families and couples.  The point of my paper is that

1) BPD got stigmatized and dismissed for years as untreatable as so is behind in research by about 20 years compared other mental illnesses and

2) when it did finally get researched, so much attention was paid to how and why BPD people gravitate toward suicidal gestures and helping with suicidal ideation…that interpersonal difficulties were reported but NOT studied.  

So, in reading the above lit review, I was really excited to see academic attention being paid to the interpersonal dynamics of BPD…and not just the individual symptoms, such as suicidal ideation and self harm.  I believe that studying the interpersonal dynamics, as finally started with Fruzetti etc,  is going to end up being the most significant factor in the prevention and treatment picture for the future,  and it’s unfortunate that it is taking so long for research in this area to take hold.

I found many items brought up in the paper to be very interesting and exciting, but I don’t have time to put it all down.  One item of interest:

From a methodologic perspective, there is a striking lack of descriptive and relevant couple data in research reports investigating BPD (eg, union status and duration). Overall, recent studies suggest that couple formation and duration are problematic processes in BPD patients. However, the relationship picture is not as negative as clinicians tend to expect it to be. In a signifi cant proportion of cases, once formed and after a period of adaptation and increased conflicts, couples in which one member suffers from BPD can reach a sort of “instable stability.” These preliminary results are interesting, but to gather a more complete picture of relationship stability in BPD, future investigations should routinely include more systematic and descriptive measures of current and past cohabitating and marital unions.

Translated, we need to study what goes on (the interpersonal dynamic)  between BPD people and their loved ones.  Both in the parent/child domain and the couple domain.  Not to point fingers at anyone, but to find out HOW to help all the people involved and to understand what exactly is going on. They are noticing already some couples seem to find a kind of ‘instable stability’ over time…so yes, let’s look at those couples and see what coping mechanisms are being employed.  What is going on there? How do they compare to other couples that crash and burn?   It may not be something we want to model, but it will probably gives us clues about what helps to make things better,  and what helps makes things worse.  Someone in a post mentioned that this Lit Review is not telling us (people in the trenches) anything new. But, this literature review is emphasizing the need to study US….the family members in the trenches.  EXACTLY!  Researchers should be interviewing US, and that is what literature reviews like this help point out to the academic community, thus spurring on further research FOCUSED on the interpersonal dynamics of those who are close to BPD people on a daily basis.  We the families and loved ones of those who suffer from BPD traditionally are not being brought INTO the treatment plan, are not being brought into the research, we are not being brought into the clinical, academic picture, and we have to be.   This is in many ways a disorder of intimacy; you have to research what is going on between two or more intimates.  This is crucial. That is what literature reviews of this type will help spur on…more and better research that takes into account the family/couple dynamic.      

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« Reply #5 on: November 03, 2014, 11:54:25 AM »

Thanks for sharing this article-- it is very helpful. What stands out to me are these findings:

1. High levels of distress for intimate partners and for parents:

The well-being of spouses or family members living with BPD patients also has gained attention recently. Scheirs and Bok [39] administered the Symptom Check List (SCL-90) to 64 spouses and parents of BPD patients. The results showed a degree of psychological distress comparable with what is normally observed in families of schizophrenic, depressive, or post-traumatic stress disorder patients. This high distress was as elevated in parents as it was in intimate partners. Our own data on the romantic partners of patients with BPD suggest that their psychological distress is twice as high as what is found in men from nondistressed couples [22•]. Hoffman and colleagues [40] showed the following: 1) family members and partners generally had little knowledge about BPD; 2) the more knowledge they had, the more depressed, burdened, hostile, and psychologically distressed they were; 3) a high degree of agreement exists between patients and those close to them on the personality traits of the BPD patient; and 4) BPD patients and those close to them disagreed on the personality traits of family members (or partners) who were perceived by BPD patients as evidencing a higher level of neuroticism and lower levels of extraversion and openness.

2. That many partners of pwBPD have personality disorders themselves:

Using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, these researchers found a 55.9% rate of personality disorder in intimate partners of women with BPD, whereas the expected rate of personality disorder in the general population is 9% to 15.7% [37]. At this early stage, it is difficult to determine whether this high proportion of potentially dysfunctional pairings refl ects poor partner choice, attraction by shared developmental failures [38], or simply a limitation in the availability of adequate partners
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« Reply #6 on: December 18, 2014, 11:27:36 AM »

" Using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, these researchers found a 55.9% rate of personality disorder in intimate partners of women with BPD, . At this early stage, it is difficult to determine whether this high proportion of potentially dysfunctional pairings reflects poor partner choice, attraction by shared developmental failures, or simply a limitation in the availability of adequate partners."

"People suffering from BPD generally represent an exacting and highly unpredictable attachment figure for their romantic partner. Also, for these couples, with an insecure attachment style generally observed on both sides of the dyad, the possibility of successful coregulation of negative affect may be almost out of reach. For example, in the Bouchard et al.  sample, both partners evidenced insecure attachment representations in 68.6% of all cases. These couples seem bound to continue feeling insecure with each other and have to resort to hyperactivating and deactivating strategies to regulate affects"



These two features of the review, really resonated with me.  Although the review did not specifically mention the type of personality disorder that is common amongst partners of pwBPD and "attraction shared by developmental features,"  I am postulating that co-dependency/DPD is the most frequent type. The traits (fixing, caregiving, helping) that are prominent in a co-dependent/pwDPD appear to be complimentary to traits found in pwBPD.   There are similarities with co-dependents/DPD and BPD forming insecure attachments and fear of abandonment. The dynamics of a relationship between co-dependents/DPD and pwBPD appear to dysfunctionally compliment each other.

I found this to be true in my own relationship.  I tend to fall more on the DPD spectrum with some co-dependent traits.  The composition of my own personality is almost a "perfect storm" for my relationship with my pwBPD.  We both have a fear of abandonment and issues with boundaries.  Prior to my therapy, our maladaptive behaviors were mutually reciprocated and exacerbated the dysfunction.  He did not take responsibility for his behavior, whereas I claimed all the responsibility for his and my behavior.  When he pushed me away, I pulled him closer. It was a circle of dysfunction, where we fed off one another. Essentially, it was the true definition of insanity; doing the same thing over and over and expecting different results. It was easier to blame the entire dysfunction on him, rather than looking at my own behavior.  

I think it would be interesting to conduct a study to find direct correlations between BPD and co-dependency relationships and insecure attachment.
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