IMPACT OF COUPLE RELATIONSHIP ON THE GENERAL FUNCTIONING OF PATIENTS WITH BORDERLINE PERSONALITY DISORDER – CASE REPORT

Borderline personality disorder, psychiatric nosologic entity defined by failures in the emotion, cognition, self and behavior continues to be a diagnostic and therapeutic challenge. Diffuse identity, emotional instability, chronic disruption of attachment behavior and interpersonal relationships lead to maladaptive and self- harm behavior (1).
We presented the cases of two borderline personality disorder patients with different evolution due to the particularities of the couple relationship. Ema, (data base of the patients were changed to maintain confidentiality) aged 31, applied for psychotherapeutic intervention for generalized anxiety, dysphoria and obsessive-compulsive symptoms caused by fear of harming her own child, aged 4. She refused psychiatric medication.
Ema came from a family with medium social status, where mother was medical professional and father craftsman. Referring to her childhood, she describes strained relations because of father’s alcoholism and aggressive behavior and mother’s efforts to ensure the basic needs and children’s education. Father was emotionally absent and occasionally abusive, and mother very stressed. Ema describes a black and white image of parental family – the mother is sublime character, model and heroine of her life and father embodiment of all negative traits. She had difficulties in community integration, because she was „a very sensitive child.”
Ema has been married for ten years with a young engineer with whom she had a relationship in the early years of high school. Mother advised her in this election and said a memorable phrase: „With him you are a better person and I became proud of you.”
Ema says that the rule of her life is „all or nothing”, that she quickly takes intuition based decisions, that she is demanding, but deeply involved in the relationship. Asked about how the husband sees her, Ema adds several features which she does not comment: she is easy to hurt, she does not give second chance and can be very tough despite her best intentions.
In relationship, Ema is seen as devoted and attentive partner, despite possessiveness, increased need for attention and affection and pretentious style. Years ago she was the soul of parties, but in recent years she has avoided them, feeling that it would be exceedingly difficult to hide her pain. Sharing her problems with friends was not taken into account. Ema describes her husband as a tolerant, kind to everyone, under authority and moral standards. He had mystical vocation, despite the fact he chose a technical trade. Both Ema and her husband are faithful practitioners that have turned to priests in difficult times of life.
Ema graduated from higher education and teaching language. She considers professional status a stability factor in her life, although describes a significant stress in relationship with colleagues and students, and numerous assessments and deadlines. She smokes half a pack of cigarettes per day, she does not consume alcohol or other substances and is extremely cautious with medication, even with medical recommendation.
Of her life’s history we have noted several episodes of bulimia-anorexia in adolescence, three episodes when she was spending significant amounts of money as antidote against depression and two episodes with depression and anxiety. During pregnancy anxious and obsessive symptoms about fetal safety began, so she refused natural birth. After the birth of the child these symptoms increased, appeared fear of harm to himself or the child, avoiding any risk situation in this field and panic attacks for which she occasionally used benzodiazepines. When the four months old baby has had several bouts of apnea in the context of bronchitis, Ema developed symptoms of PTSD and, three months later, depression, which is why she addressed to a psychotherapist. She said that the few meetings have not helped her, so she gave up. Affirmatively, Ema’s mental condition has improved after returning to employment and social life.
The mental status examination revealed: suspicion, obsessive ideation that would be able to hurt the boy, prevalent ideas of relationship, tracking and damage (including to the therapist, not only family and colleagues), obsessive guilt ideation (being a bad mother), dysphoria, anhaedonia, generalized anxiety, panic attacks, negative expectations, fear of going crazy, emotional instability, crying easily, impulsivity, ambivalence towards persons of reference, decreased will and interest in daily activities and performance, psychomotor restlessness, compulsive aggression against the child and avoidant behavior in order not to stay alone with the child, loss of appetite, insomnia and depersonalization.
The diagnosis is recurrent depressive disorder, actually episode of moderate depression, obsessive- compulsive disorder and borderline personality in observation.
We do not know for sure the diagnosis of her personality disorder, because Ema avoided the questions about her personality and we lacked heteroanamnesis. Because the appearance, the elite social status and relationships were very important for her, because she was demanding and bossy, Ema looked like a narcissistic personality. But in the therapeutic relationship was revealed that these attitudes appear to be secondary to other issues such as: the need to be in constant contact with a reference person (mother initially and after that husband and son), setting symbiotic relationship with abolished interpersonal boundaries, transgressing boundaries in interpersonal relationships, excessive need for affection and possessiveness, self-image with major and rapid fluctuation, white and black model of thoughts and affection, projective identification, very high standards for himself, tendency to self-blame, shame, guilt, self- hatred and anger. The situations characterized by negative emotions such as rejection, loss, separation, helplessness, hopelessness, shame, guilt, loneliness, boredom, etc. represented in certain circumstances triggers for panic a t t a c k s , p s y c h o m o t o r a g i t a t i o n o r a g g r e s s i v e interpersonal conflict. After that, she felt very guilty, ashamed and wanted to be punished (2). Ema did not answer the question concerning acts of self-harm and did not describe aversive experiences like inner emptiness, but intense anxiety.
Ema recognized as an important stability factor of her life that she had a supportive relationship with her husband, who spared „acute” issues of its nature and „minimized conflict and crisis situations.” But stress related to pregnancy and childcare subsequently forced to the maximum the capacity of the couple to cope with the new situation. To this stress, Ema responded by emphasizing her personality’s features and combined symptoms of anxiety, obsessive-compulsive, depressive and paranoid. Her husband presented emotional distancing, self-closing and sometimes the use of alcohol.
Although she asked for therapeutic help, avoidant behavior of Ema was persistent, because she kept silence on important aspects of her life and canceled at the last minute every second meeting. After six sessions of therapy she gave up without notice. Unexpectedly, she returned three months later, considering that no discontinuation appeared.
The particularity of this case is the good professional and familial level functioning, because of an appropriate couple relationship.
Another feature of the case were the therapist’s difficulties in working with the conflictual emotions and cognitions mixture such as openness, compassion, irritation, being flattered, being wronged, being controlled, helplessness and feeling that will not get anywhere with the therapy, inability to integrate the case’s complexity, relief when Ema gave up therapy. For some emotions the therapist could create framework for discussion and explanation, others were accounted and kept in silence waiting for the right moment (3).
The second case that we discuss is that of Alex, whose biographical journey was negatively affected by the couple relationship. Alex, a male aged 30, was admitted for a voluntary suicidal behavior made with 2000 mg carbamazepine and 10 tablets of Ibuprofen. On admission he presented somnolence, psychomotor inhibition and refusal to communicate with medical staff. He only said „I want euthanasia”. After a day, his condition has improved and we could initiate a therapeutic discussion.
Alex was born into a family with unknown father and a mother hardly keeping a job. He has two older brothers whom he knows very little because about 9 months age he has been given to a placement center, where he remained until the age of 18. After that, his mother invited him to live with her.
Alex describes a sad and oppressive life in „orphanage”. Older children scared, injusticed and humiliated little ones and that was the every day „normality”. Sometimes in the summer, Alex went to live in his grandfather’s country house, where he felt strange, inappropriate and very lonely. There, in a fit of depression, the 8 years old boy, had his first suicide attempt by hanging. Alex was found by his grandfather who, frightened by his nephew mental problems, immediately led to Placement Center, without ever looking for him again.
Alex was a good student and graduated without difficulty the School of Accountancy, but at that time started using abusive alcohol. He did not use major drugs but he intermittently used psychiatric medication.
From the age of 23, he had a relationship with a girl a few years older, diagnosed with borderline personality and schizoaffective disorder, who met during a psychiatric hospitalization. She was unlicensed graduated from the Faculty of Psychology, but never practiced in this field. She sporadically worked having difficulties in keeping a job. She was attracted to promiscuous professions, so they were having several serious argues.
Alex says that they were having a „now in heaven, now in hell” relationship, which had a nice beginning and a disastrous continuing. Alex loves movies and describes his life using metaphors and images of his favorite ones. Being inspired by the movie „Beautiful Mind”, he dedicated his life to the loved girl, which was perceived as exciting, intelligent, creative, but the victim of the wrong parental education. Alex has a tendency to minimize her unacceptable traits and assigning responsibility for her destructive attitudes to someone else, including himself.
Alex’s girlfriend, known to the therapist due to many psychiatric hospitalizations, is an emotionally unstable person, with impulsive, sarcastic, manipulative and aggressive behavior, who sabotages collaboration and hospital rules. In their couple relationship Alex successively dropped hobbies, personal and professional values in order to stop his partner’s reproaches and threats of separation. Alex describes several common pattern situations: being well paid he worked about eight to ten hours a day, but his partner was unhappy with his absence from home. She came to the office and triggered a scandal involving the unit management, that determined Alex’ dismissal. This scenario was several times repeated and followed by financial hard times when he had to move with his mother.
Relational and professional failures, the feeling of being used and abandoned, the incapacity to have an harmonious relationship and the bouts of depression, urged Alex to self-harm. Once hospitalized, his partner was visiting, talking and resuming the relationship. Alex says he can not live without his girlfriend, although intensely suffering in this relationship. He talks a lot about her and very little about their one and half old age son, who is living with his mother.
Alex describes himself as a sensitive, dependent person with tendency to sacrifice and lose himself in the couple relationship. He suffers a lot when is criticized and rejected and he can not bear to be abandoned. Alex says that he easily scares and dramatically moving from a mental state of comfort to intense fear or desperation. Usually, he solves those situations by use of alcohol or by harming himself. Alex considers himself a humble man who does not deserve respect and urges us not to call him „Mr. …” because that was not fit to him. He describes difficult and intense suffering caused by rejection, criticism, irony, indifference or lack of attention. He says that the hardest to bear is that „inner pain, accompanied by terror and helplessness” which we considered to be the inner emptiness. He describes inner emptiness especially when he is alone and he then generally attempts self- harming. According to Alex, avoiding a great suffering (feeling empty inside) can be realized by a less severe one, as self-harming or even killing himself.
Alex’s psychiatric history includes many moderate or severe depressive episodes installed in situational context, most commonly by relational conflicts. Those were usually accompanied by phenomena of self-harm and abuse of ethanol. The psychiatric exam after remission signs of drug intoxication revealed depressive symptoms, so he received SSRIs, mood stabilizing and anxiolytic. His diagnosis is recurrent depressive disorder, actually severe depression episode without psychotic symptoms and borderline personality disorder.
Alex asked transferring in a chronic psychiatric hospital, where he could stay for at least a year in order to „take time for calming himself”. He believes that this is the only way to stay alive and get a new beginning. During the current hospitalization, Alex has behaved like any other depressed patient without obvious psychopathic behavior. The therapist did not assume special difficulties in emotions management.
Comparing features of the two cases, we consider that Ema presents borderline and narcissistic personality traits, which led to advantages and disadvantages. We believe that the narcissistic defenses have brought her a bit of stability in self-image, interpersonal relationships and in setting goals, ambition and perseverance compared with other borderline personalities (4). They also helped in getting a good professional and familial status. We believe that narcissistic traits protected Ema from self harm behavior. The disadvantage of combined borderline and narcissistic traits could be seen in the interpersonal stress and disruptions The emotional and cognitive material that Ema exposed in therapy put a significant pressure on the therapist, who did not find adequate resources and time to cultivate a good therapeutic relationship. In conclusion, we believe that Ema presents a moderate borderline personality disorder with medium impact on overall functioning.
We believe that Alex presents combined borderline, dependent and depressive traits. His biographical analysis indicates that dependent and depressive traits contributed to professional setbacks and a self-destructive couple relationship. In conclusion, we consider that Alex suffers from a severe personality disorder with a significant impact on overall functioning. However, we believe that dependent and depressive traits favored a good start for therapeutic relationship, where Alex was involved as deeply honest as he could.
We are invited to reflect on what could help people with a personality disorder.
Is it preferable to associate features that ensure a better functioning but give less chance of awareness or to present disturbing traits that favor requesting and receiving help?
We consider that the answer lies in the further development of Alex and Ema, whom we believe we will meet and understand better in the future.

REFERENCES
1.Millon T, Millon CM, Meagher S, Grossman S, Ramnth R. Personality Disorders in Modern Life. New Jersey, Hoboken: John Wiley and Sons Inc, 2004, 477-518.
2.Young JE, Klosko JS, Weishaar M. Schema Therapy: A Practitioner
Guide. New York: The Guiford Publications, 2003.
3.Giesen-Bloo J, van Dyck R, Spinhoven P et al. Outpatient Psychotherapy for Borderline Personality Disorder: a randomized trial of Schema focused therapy versus Transference focused therapy. Archives of General Psychiatry 2006;(63)6: 649-658.
4.Linehan M. Cognitive Behavioral Therapy. NY, London: Guilford
Press, 1993.

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