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ISS & MLB︱September 24-26, 2013 PREDISPOSED BORDERLINE PERSONALITY DISORDER (PreBPD) Dr. Marietta B. Rasonabe, RGC, RP Colegio De San Gabriel Arcangel –San Jose Del Monte, Bulacan ABSTRACT Borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image and emotions. The unstable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings; at work, home, and often accompanied by a similar lability -fluctuating back and forth, sometimes in a quick manner - in a person’s emotions and feelings. The person must be at least 18 years old before they can be diagnosed with it, (Grohol,J, 2012). The study anchored on DSM-IV-TR - Axial II clustered B on the symptoms of BPD as well as it used self-concept, interpersonal relation and family environment as its determinant factors on the prevalency of the symptoms. Purposive sampling was employed among 325 college students from private and a public locally funded university in Metro Manila, whose mean age is 19.31 years old. Results showed: 13.85% or 45 students of the sampled respondents were predisposed to Borderline Personality Disorder (BPD). Regression analyses showed that; self-concept predicted fear of abandonment, unstable self-image, and paranoia, while family environment predicted chronic emptiness and boredom as well as suicidal behaviour. Key words: Predisposed Borderline Personality Disorder (PreBPD), self-concept, interpersonal relations, family environment ISS 998 ISS & MLB︱September 24-26, 2013 This study is a preliminary investigation on Predisposed Borderline Personality Disorder (BPD) among Filipino College Psychology students enrolled in public and private universities of Metro Manila. Specifically, it tried to answer the question; Are there relationships between the predisposing factors of Pre BPD and to the self-concept, interpersonal relation and family environment? Hypothesis (Ho) There is no relationship between the predisposing (Pre BPD) factors and to the self-concept, interpersonal relation and family environment Schematic Diagram: Co-related factors *Self-Concept *Interpersonal relation *Family environment Predisposed Borderline Personality Disorder Instruments: The BPD Test The study adapted the (Grohol, J. 2012) BPD test which was also based from DSM-IV TR Axis II Cluster B (American Psychiatric Association, 2000). The instrument consisted of nine items answerable by yes or no and also based on the following nine factors of Borderline Personality Disorder. 1. Frantic effort to avoid real or imagine abandonment. 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., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). 5. Recurrent suicidal behaviour, gestures, threats or self-injuring behaviour such as cutting, interfering with the healing of scars or picking at oneself. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness and boredom. 8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms. At least five (5) of the above mentioned symptoms must be manifested to diagnose BPD and he must be 18 years old at the time of diagnosis. "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." There is some evidence that BPD diagnosed in adolescence is predictive of the disorder continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen (DSM IV –TR ). The Sacks Sentence Completion Test ISS 999 ISS & MLB︱September 24-26, 2013 The Sacks Sentence Completion test was administered for self-concept, interpersonal relation and family environment. Dr. Joseph M. Sacks, designed this test to obtain clinical material in four areas of adjustments: family, sex, interpersonal relation and self-concept. It has felt that items included in this test present sufficient opportunities for the subject to express his attitudes so that clinical psychologist may infer his dominant personality traits or trends. Such information is useful in screening patient for therapy, which gives clues to content and dynamics of patient’s attitudes and feelings. In this study the sex and interpersonal relation variable were considered as one. It is a sixty (60) item-test, in the following group of variables: 1. The nature of the Family scale: the family area includes the three sets of attitudes namely towards father, mother, family unit. It is hope that even when the subject is evasive or cautious at least one of the four items will reveal significant response. 2. The Sex Area: The sex area includes attitude towards woman and heterosexual relationship. The 8 items in this area allows the subject to express himself with regards to woman towards to marriage and with respect to sexual relationships. 3. Interpersonal Relation – this area includes attitudes towards friends and acquaintances, colleagues at work or school, superior at work or school or people supervised. The 16 items in this area allows the subject to express his feelings. 4. Self-concept – this area includes fear, guilt feelings, goals and attitudes towards one’s own ability, concept of himself as he is and hopes. There are 24 items in this area. Scoring and interpretation A rating sheet has been devised for the SSCT which brings together each attitude, the four stimulus item and the subjects responses. It is scored by 2 - if severely disturbed, 1- if mildly disturbed, and 0 if no disturbance and x if insufficient evidence. The BPD test was validated to students who were not included in the sample using the Confirmatory Factor Analysis (CFA) and yields x2 = 0. 85; which is considered high and acceptable. The Sacks sentence completion test was not validated because it is a projective test. Respondents of the Study The respondents of the study were from the two universities; private and public in Metro Manila. The private university caters to low and average socio-economic status families while the public university was locally funded university and majority of the students came from low socio-economic status. Sampling technique employed was purposive –cluster and included all students taking up psychology courses handled by the professor –researcher herself. The Hotel and Restaurant Management course in the private university numbered to one hundred forty nine (149) while half of the respondents who came from the Business Management course was from the public university, which numbered to one hundred seventy six (176); of which 1/3 are males and 2/3 are females of the total three hundred twenty five (325) student respondents. Procedure in the administration of the two instruments At the middle of the semester; the PreBPD test was administered to all students in general psychology handled by the professor researcher after validating the instrument. One consideration in sorting out the respondents was he/she must be 18 years old. Then, it was checked manually. After checking, the next consideration was the Pre BPD score; if the respondents scored 5 or more he/she was a candidate to be a student-respondent participant. The result was from the private university; nine (9) were males, public university only three (3) were ISS 1000 ISS & MLB︱September 24-26, 2013 males, while the females; private university, nineteen (19) and public university were fourteen (14). A total of forty five (45) student- respondents out of three hundred twenty five (325) or 13.85% showed Pre BPD symptoms. Then after, the forty five (45) Pre BPD symptom respondents were identified, they were again given another test which is the Sacks Sentence Completion Test for the determinant variables of: self-concept, interpersonal relation and family environment. RESULTS Table 1 Descriptive Statistics of the variables variables N Fear of abandonment Chronic emptiness & boredom Impulsivity Suspicious ideas & parnoia Unstable self-image Recurrent suicidal behaviour Anger control difficulty Anxiety & panic attacks Over idealizing & devaluing 45 45 45 45 45 45 45 45 45 Minimum Maximum Mean 0 1 0.7333 0 1 0.6222 0 1 0.3333 0 1 0.8222 0 1 0.8 0 1 0.2667 0 1 0.6222 0 1 0.9556 0 1 0.8222 Std. Dev. Variance kutosis skewness 0.44721 0.2 -0.847 -1.092 0.49031 0.24 -1.81 -0.522 0.47673 0.227 -1.535 0.732 0.38665 0.149 1.089 -1.744 0.40452 0.164 0.426 -1.552 0.44721 0.2 -0.847 1.092 0.49031 0.24 -1.81 -0.522 0.20841 0.043 9.811 -4.575 0.38665 0.149 1.089 -1.744 Table 1 presents the means, standard deviations, variance, kurtosis and skewness of the variables. It describes the symmetric properties of the normal probability curve (Adanza, 2006), but one thing either the curve is skewed to the left or to the right, is not normally distributed. The direction of the variables leans towards the negative side. However, standard deviation and variances showed normality as its values are very close to zero. As a whole, the student respondents had a high level of anxiety and panic attacks, over idealizing and devaluating people, suspicious ideas and paranoia, unstable self-image, and fear of abandonment as the predisposing factors of BPD. The family environment accounted for the suicidal behaviour in this study as one of its influential factors, and the interpersonal skills relation positively relates to the family environment. Table 2 Correlations of the Variables ISS 1001 ISS & MLB︱September 24-26, 2013 variables age age gender 1 2 3 4 5 6 7 8 9 10 11 12 1 gender 0.114 1 abandonment 0.272 -0.25 1 boredom 0.094 0.048 -0.263 impulsivity -0.03 paranoia 0.076 unstable image 0.114 0.114 0.075 -.302* -.343* 1 0 -.320* -.324* 0.013 0.25 -0.205 -0.152 anger control 0.094 -0.159 0.048 -.324* 0.114 -0.13 -0.168 0.154 over idealization 0.259 self-concept -0.238 .492** .300* interpersonal relation family environment -0.149 .377* 0.206 -0.275 -0.013 0.049 -0.12 1 0.183 -0.118 -0.087 suicidal behaviour panic attack 1 0.117 -0.288 -.362* 0.162 -0.003 0.152 1 -0.16 0.159 1 -0.1 0.162 -0.114 0.054 0.082 -0.216 -0.232 0.018 -0.278 -0.056 0.063 1 0.107 -0.245 -0.075 -0 1 -0.1 1 0.267 -.430** -0.233 0.062 0.054 0.173 0 -0.139 -0.114 0.052 -0.053 -.392** 0.077 -0.041 -0.277 .300* 0.22 0.037 0.119 0.207 0.003 0.03 1 0.005 1 0.221 .323* *. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed). Table 2 presents the inter-correlation and regression analysis of the studied PreBPD variables. Apparently, age positively relates to self-concept but negatively relates to unstable self –image. It means that as they mature in age their image remains unstable. Fear of abandonment positively relates to: over-idealization and self-concept but negatively relates to impulsivity and unstable self-image. Although they feared abandonment still they are impulsive and had unstable self-image. Chronic boredom and emptiness negatively relates to; impulsivity, anger control difficulty, over-idealization and devaluation and family environment. Family environment was influential and contributing factors of chronic boredom. The unstable selfimage negatively relates to self-concept, which means the stability of the self-image is embodied in the view of the self-concept as a whole. Table 3 Regression Analysis: Self-Concept as Predictor Variable BPD variables fear of abandonment chronic boredom & emptiness Impulsivity suspicious ideas or paranoia unstable self-image recurrent suicidal behaviour anger & control difficulty anxiety and panic attacks over idealizing or devaluating people Beta 0.524 -0.187 -0.079 0.282 -0.392 -0.319 0.03 0.059 0.184 B 0.075 -0.029 -0.012 0.035 -0.051 -0.46 0.005 0.004 0.023 T 3.836 -1.326 -0.095 1.844 -2.771 -2.209 0.191 0.371 1.177 Sig 0 0.192 0.623 0.072 0.008 0.033 0.849 0.713 0.246 Self-concept, highly predicted the condition of “frantic effort to avoid real or imagine abandonment by people close to me”, in one of the PreBPD factors. In the study also of ( Ayduk, et al. 2008), found that rejection sensitivity and executive control are predictors of BPD symptoms; in other words, people who are highly apt to feel rejected, are those who have poor ISS 1002 1 ISS & MLB︱September 24-26, 2013 control of their emotions and behaviour, are more likely seen BPD. Attachment studies have revealed a strong association between BPD and insecure attachment style, the most characteristic types being "unresolved", "preoccupied", and "fearful" (Agrawal, 2004). The self-concept variable in this study is a predictor on the fear of abandonment. Table 4 Regression Analysis: Interpersonal Relation as the predictor variable BPD variables Beta fear of abandonment chronic boredom & emptiness Impulsivity suspicious ideas or paranoia unstable self-image recurrent suicidal behaviour inappropriate anger & control anxiety and panic attacks over idealizing or devaluating people -0.012 0.198 -0.034 -0.12 -0.056 -0.074 0.173 0.045 0.136 B -0.076 0.033 -0.005 -0.016 -0.008 -0.011 0.029 0.003 0.018 T Sig -0.541 1.36 -0.205 -0.76 -0.387 -0.5 1.082 0.27 0.843 0.592 0.181 0.839 0.451 0.701 0.62 0.286 0.788 0.404 Table 4 indicates the regression analysis of the interpersonal relation as the determinant variable. Although, in this study interpersonal relations did not predict somehow, but person with this type of disorder commonly have problems with his interpersonal skills and adjustments, because it has its co appearance with other behaviour disorder. Table 5 Regression Analysis: Family Environment as the predictor Variable BPD variables fear of abandonment chronic boredom & emptiness Impulsivity suspicious ideas or paranoia unstable self-image recurrent suicidal behaviour inappropriate anger & control anxiety and panic attacks over idealizing or devaluating people Beta -0.076 -415 0.105 -0.065 -0.172 0.395 0.145 -0.025 -0.055 B -0.145 -0.082 0.02 0.01 -0.028 0.071 0.029 -0.002 -0.009 t -1.001 -2.782 0.625 -0.401 -1.151 2.582 0.886 -0.145 -0.33 Sig 0.323 0.008 0.535 0.691 0.256 0.013 0.381 0.885 0.743 Table 5 shows the regression analysis on the family environment as the predictor variable of BPDs. As shown, it predicts chronic boredom and emptiness and recurrent suicidal behaviour of the respondents. The family environment as one of the predictors of BPD accounted as negativity in the chronic boredom and emptiness. The negativity of the persistent environment can influence to the behaviour of a growing child and can result to emptiness and boredom. It is of utmost important that family environment must be healthy to have a healthy predisposition in life as the most influential factor in the growing up of a child. As well as the negative self-image if not properly address can lead to self-injurious or suicidal tendencies behaviour. DISCUSSIONS ISS 1003 ISS & MLB︱September 24-26, 2013 Onset of symptoms typically occurs during adolescence or young adulthood. While borderline personality disorder can manifest itself in children and teenagers, therapists are discouraged from diagnosing anyone before the age of 18, due to adolescence and a stilldeveloping personality. There are some instances when BPD can be evident and diagnosed before the age of 18. The (DSM-IV, 2007) : "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." There is some evidence that BPD diagnosed in adolescence is predictive of the disorder continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen. BPDs are often intelligent and paranoid. They often convince themselves that those who try and help them are "out to get them" or that family members and therapists are crazy themselves. 13.85% of the students –respondents were high in anxiety and panic attack, suspicious over idealizing with unstable self-image. BPDs self-image can also change rapidly from extremely positive to extremely negative. (Parker, Boldero and Bell, 2006) examined another facet of BPD, which is instability of the sense of self. Their findings indicated that Self-Discrepancy—the sense of failing to match one's own ideals—was strongly correlated to BPD. Self-complexity, or being aware of one's own mental patterns, was not. Among those high in self-complexity, the relationship between selfdiscrepancy magnitudes and BPD features was lower than among those with less self-complexity. Actual-ought self-discrepancy relationship with BPD features was not significantly moderated by self-complexity. There are sudden and dramatic shifts in self-image, characterized by shifting goals, values and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with borderline personality disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations, (Grohol, 2012). Suicidal or self-harming behaviour is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging (Hawton, 2000). (Gunderson 2011), self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent. (Saloff, 1994), on -going family interactions and associated vulnerabilities can lead to self-destructive behaviour. Stressful life events related to sexual abuse can be a particular trigger for suicide attempts by adolescents with BPD tendencies (Horesh, 2003). Self-injurious behaviour includes suicide and suicide attempts, as well as self-harming behaviours. As many as 80 % of people with borderline personality disorder have suicidal behaviours, (Linehan, 2006) and about 4 to 9 % commit suicide, (Zanarini, 2006) .Suicide is one of the most tragic outcomes of any mental. Suicide is one of the most tragic outcomes of any mental illness, (Linehan 2007). Some treatments can help reduce suicidal behaviours in people with borderline personality disorder. For example, one study showed that dialectical behaviour therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment, (Linehaan ISS 1004 ISS & MLB︱September 24-26, 2013 2007). Unlike suicide attempts, self-harming behaviours do not stem from a desire to die. However, some self-harming behaviours may be life threatening. Self-harming behaviours linked with borderline personality disorder include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with borderline personality disorder may self-harm to help regulate their emotions, to punish themselves, or to express their pain, (Kleindienst N, et. al. 2008). They do not always see these behaviours as harmful. Borderline personality disorder and mood disorders often appears concurrently, (Robinsons 2005). Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment, (APA 2007). Both diagnoses involve symptoms commonly known as "mood swings." In borderline personality disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation. The behaviour is typically in response to external psychosocial and intrapsychic stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours, days, weeks or months, (Nelson 2009). Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked non-reactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute. The disorder typically involves an unusual degree of instability in mood and black-and-white thinking, or splitting. BPD often manifests itself in idealization and devaluation episodes and chaotic and unstable interpersonal relationships, issues with self-image, identity, and behaviour; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation (APA, 2000). Splitting in BPD includes a switch between idealizing and demonizing others (absolute good/love vs absolute evil/hate with no "grey area"). This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances may also include harm to oneself (Robinson , 2005). Without treatment, symptoms may worsen, leading (in extreme cases) to suicide attempts. As it is intertwined with the other factors of BPD tendencies, the self-concept of a person is always a determinant factor of psycho-social well – being both at work, and all his social facets in life. This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children. The families of those with it and has a lot to do with psychosocial and environmental factors, rather than belonging strictly in the personality disorders and mental retardation. (Mckinnon, 2006), parents of individuals with BPD may show co-existing extremes of overinvolvement and under-involvement. In this study, the involvement of family especially the parents may develop the chronic boredom and emptiness of their children. (Skodol , 2003) found that child sexual abuse (CSA) and childhood physical abuse both directly influence the development of BPD symptoms and are mediated by family environment. Implications to clinical psychologist and counsellor/ therapist. Implications of the Study ISS 1005 ISS & MLB︱September 24-26, 2013 The findings of this preliminary study; is very important for counsellors/ therapist and especially psychologist, for the development of its intervention programs. Much help can be generated if attention to this kind of problem is properly addressed. To educate the public of this disorder is very difficult so far but if helping professionals will give attention to it, this could be lessen and would be of great help to those who have this symptoms. 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Acta Psychiatrical Scandinavica 120 (5): 373–377. Zelkowitz P, Paris J, Guzder J, Feldman R. Diatheses and stressors in borderline pathology of childhood: the role of neuropsychological risk and trauma. J Am Acad Child Adolesc Psychiatry. 2001 Jan;40(1):100–5. About the researcher MARIETTA B. RASONABE, PhD, RGC, RP (RGC) Registered Guidance Counselor (RP) Registered Psychologist Doctor of Philosophy in Psychology, Master of Guidance & Counselling, MAT Mathematics Scholarships: Monbusho Scholar to Japan: Japanese Language –Nagoya University, Special Education for the Blind Aichi University of Education, Aichi, Japan Japan Foundation Scholar: On Japanese Language Teaching Saitama International Centre, Saitama, Japan DOST-UPLB Scholar on Research Graduate School Professor: Technological University of the Philippines –Manila (2010-present) Professor: Japanese Language, University of Santo Tomas, Manila (1998-2008) Guidance Counsellor: Philippine National School for the Blind (8 years -1988-1995) Guidance Director Pamantasan ng Cabuyao (2 years -2010-2012) Research Presenter: Japan, Malaysia & Philippines Published Books authored & co-authored Japanese Language Books: Conversational Japanese Japanese Tourism Language 1,2,3 Psychology General Psychology in Press Counselling Psychology in Press Methods of Research A Primer –co authored Researches Presented & Accepted: 1.Neuro-Linguistic Programming for Behaviourally Disturb -Presented ARUPS 2010-Malaysia 2.Personal Survival Skills and Techniques -Presented PGCA 2010 Annual Convention 3.Taming the Storm: Collections of People’s Problem and its Therapy Applied- PGCA 2011 4. Morality in Harmony with Bio Diversity-accepted World Bio Diversity Congress 2011 5.Multiple Intelligences of Visually Impaired Students – PAP Convention 2012 Cebu City 6. Pre Borderline Personality Disorder –Paper Accepted: Seminar - Sept., 2013, Nagoya ,Japan 7. Personal Survival Skills and Social Responsibility: Accepted ARUPS 2013, Manila ISS 1009