Recovery Is a War Against Genes and Environment

There is an illness called borderline personality disorder (BPD); its main clinical features are dysregulation of emotion, cognition, behavior, and self and identity. BPD patients easily fall into deep emotional pits and are often comorbid with depression, anxiety disorder and post-traumatic stress syndrome. They handle their relationships and personal feelings poorly and frequently clash with those around them.

The patients cannot control their emotions either; within a single day their mood swings like a roller coaster, now at the peak, now at the trough. Once a patient falls into a bad mood, they need far more time than ordinary people to recover. They often live in fear, and what frightens them most is being abandoned; they are extremely insecure and do not know what their true self is.

Borderline personality disorder has the highest suicide rate of all mental illnesses; about 10% of BPD patients die by suicide, and many others engage in self-harm and self-directed mental attack. In fact, the great majority of BPD patients are kind-hearted, gentle and sensitive; when they are well they are the most considerate people in the world, wonderful to their relatives, friends and spouses. So when they turn on themselves, it plunges their whole family into extreme suffering. And their lovers often leave them, unable to understand their unpredictability.

The innate genes and acquired experience of such patients both have major effects on their illness. Generally speaking, they are born fragile and have had rough lives, so they easily sink deep into painful emotions and find it hard to pull out. But surprisingly, many BPD patients recover without medicine after they turn forty.

The reason may be that these patients have long been sunk in pain, and this pain drives them constantly to seek ways to save themselves and constantly to reflect on their own thoughts and behavior; so at a certain point they recover. Recovered BPD patients are reasonable and amiable; though they still carry much grief (because their life-ground is grief and they have suffered many major traumas), they are kind and gentle, no longer provocative, and a changed person from before.

BPD patients have a basis of physiological change; their brain structure differs from ordinary people, with relatively small amygdalae and hippocampi, so they are easily controlled by bad moods and have poor memory. They find it hard, like normal people, to form holistic judgments about the world based on complete information. Their prefrontal cortex is also impaired, which leaves them always in emotional storms. Their thalamic-adrenal emotional response axis is far more sensitive than ordinary people's.

We readily understand a person blinded by optic-nerve damage, yet cannot understand BPD patients, who have suffered similar neural damage. Because they seem always moody and have some aggression toward those around them (mostly verbal), and their behavior makes them seem crazy. The word "borderline" describes patients in a zone between neurosis and psychosis. Actually, the great majority of people have some degree of borderline personality tendency, but in most the clinical expression is so mild it does not affect life; only about 1.6% are diagnosed with BPD.

To laypeople, the inner world of a BPD patient is a puzzle; specialist doctors too find such patients perplexing. They lack trust in people (including doctors); they are called "consultant-killers," often abandoning treatment because they do not trust their counselor. Actually, if there is one person they can trust long-term, they are nearly recovered. Because the greatest problem of BPD patients is their inability to build long-term trusting relationships; they cannot resolve the deep conflict in their attachment relations. Once that is resolved, the other problems fall into place. So if a BPD patient has one person they can trust 100% long-term—whatever role that person plays in their life—they recover.

BPD patients are always exploring, searching the world for someone they can trust, to heal their own disorientation. Their sensitive hearts mean that the instant they sense the slightest coldness in another's behavior, they flee. So their romantic and friendship relations are very unstable. They crave understanding, but those who understand them are rare; their inner world is so mysterious that many people—including counselors—suffer greatly in contact with them.

They keep trying new relational environments. As they age, hormone levels fall and experience grows, and they become more and more inclusive, able to achieve partial acceptance. If at that point they meet someone who relatively understands them, they gradually recover. They are often misdiagnosed as depression or bipolar disorder, and sometimes as schizophrenia.

Medicine has recognized this illness only in the last twenty or thirty years; even now, many first- and second-tier cities have no hospital able to diagnose it. But some frontier research continues, and clinicians have found many drugs and methods that can improve these patients' symptoms—for example, mood-stabilizing and antiepileptic drugs have some effect, and dialectical behavior therapy helps somewhat.

From the course of this disease I see hope for recovery. The cause of any disease is no more than two factors: innate genetic defects and acquired environmental influence. BPD patients themselves change by constantly switching their living environments and building new relational worlds, and with the natural ebbing of hormone levels, they are able to recover. Of course, if they can be diagnosed earlier and treated, the patients and their families recover faster; they need not wait until after forty to self-heal, but can recover in their twenties. This would greatly improve their quality of life and save them major financial loss.

In my retrospective summary now, I find I have encountered perhaps four or five BPD patients. Their behavior is usually deeply puzzling; the symptoms they show often include ready rage, anorexia or binge eating, hypersomnia or insomnia, frequent crying, self-mutilation or suicide, alcoholism and even drug abuse, and in some even sexual addiction or frigidity. They are in extreme inner pain, but outsiders do not know it; they relieve their pain through all manner of outlandish acts. Because there are few doctors in China who can diagnose this, their families are usually at their wits' end; some bring them to TCM for help.

What these patients actually need most is understanding and companionship. Moderate medication helps somewhat, and dialectical behavior therapy helps somewhat, but both matter far less than understanding and companionship. Yet most relatives and friends who accompany them end up tormented beyond bearing. This in turn worsens the patients' guilt and self-reproach; unable to escape the illness, they always feel they are a burden to their families, and in the end choose suicide to end it all.

But what I want to say here is: if you are a BPD patient torturing yourself, believe me—your suicide is the outcome your family can least accept; it will plunge them into an abyss of pain, not free them. You must hold onto hope, believe you can recover, and endure until after forty; you will find yourself greatly changed. Under normal circumstances BPD patients are very good to their own families, far better than average people; so when they leave this world, it is their families who suffer most.

For BPD patients, recognizing their own illness is very meaningful. Once they identify their illness, know its cause and prognosis, their pain is greatly lessened. The stories of those who have recovered fill them with hope.

Borderline personality disorder reminds me of many other diseases. Actually, most hard-to-cure diseases, cancer included, could in theory also be cured if the pathogenic environment were removed and the gene-driven signal for excessive cell proliferation cut off. People cured of cancer are by no means rare in the world; in children's neuroblastoma, in particular, there are cases of recovery without medicine.

A doctor's role in such diseases is limited, but if we can find effective ways to promote patients' self-healing and shorten their period of self-exploration, their quality of life improves greatly. For example, if a BPD patient meets a good doctor in their twenties, with the doctor's help they may escape their predicament in only five or six years; in future that time may even be shortened further. Then they need not suffer until their forties, waiting for sex-hormone levels to fall before gradually recovering.

I even suspect that endocrine drugs like tamoxifen, used for breast cancer, would have a good effect on BPD patients; because some female BPD patients recover around the time of menopause or not long after, and their episodes usually occur during menstruation and ovulation. But this is only a bold personal guess; there are as yet no clinical reports on treating BPD with endocrine therapy. I may personally, when I meet BPD patients in future, try something along these lines—new ideas always have to be explored.

Some breast and prostate cancer patients have their disease-free survival greatly extended by endocrine therapy, some never recur; usually such patients also have a good prognosis after sex-hormone levels naturally decline. I find it hard not to associate breast and prostate cancer with BPD; the two have much in common, and both seem closely tied to reproduction.

Usually, the anxiety BPD patients show in parent-child relationships is far higher than normal, and some of my breast- and prostate-cancer patients are the same: they feel both a strong protectiveness and great harshness toward their own offspring. So these diseases may all arise from genetic variation caused by reproductive issues in the course of evolution. Falling levels of estrogen, progesterone and androgen would benefit such patients.

Moreover, 60% of BPD is heritable. I do not know whether their BRCA genes carry mutations, but I know breast and prostate cancer are also commonly hereditary; some breast-cancer patients have BRCA mutations, and breast-cancer patients are also highly emotional. TCM long ago held that breast cancer is caused by discord between a woman and her husband and parents-in-law.

I think we could in future do more associative research on these two classes of disease; there may be some breakthroughs. Perhaps we could treat breast cancer also as a mind-body disease: use mood-stabilizing drugs for breast-cancer patients, and endocrine-suppressing drugs for BPD patients. The same line of thinking could be tried in clinical trials on ovarian and prostate cancer. Such attempts might simultaneously improve the treatment of these diseases—but this is only my personal guess, to be verified by clinical trials.