Borderline Personality Disorder (BPD) is one of the most frequent Personality Disorders (PD) in healthcare services, affecting between 1.2% and 6% of the general population (Grant et al., 2008; Lieb et al., 2004) and up to 37% of the clinical population (Ryan, et al, 2016). It is characterized by a "pattern of instability in interpersonal relationships, affectivity, and self-image, and significant impulsivity that begins in early adulthood and is generalized to different contexts" (American Psychiatric Association, 2013). Likewise, people suffering from this problem may present hetero- and self-aggressive behaviors, as well as suicidal or self-destructive conducts (Fernández Guerrero, 2007).
One of the main characteristics of people with BPD is their way of relating to others, which results in intense and unstable relationships. In fact, seven of the nine criteria for the BPD diagnosis have a direct effect on their relationships (Hoffman, et al, 2007), so that this disorder affects not only the diagnosed person, but also his or her environment (Giffin, 2008). The family setting plays a very important role in the evolution of the symptomatology. Linehan's biosocial theory of BPD (1993) proposes that individual and environmental characteristics influence each other in triggering borderline symptomatology. According to Linehan (1993), people with BPD start from a triple vulnerability: greater sensitivity to emotional stimuli, greater reactivity to emotional cues, and a slower return to their emotional baseline. This vulnerability and a lack of skills in the environment, that is, others’ responses to the patient’s internal experiences, contribute to the onset of emotional dysregulation (Fruzzetti & Iverson, 2006).
Given the strong individual and social impact of BPD, this disorder is one of the psychological problems that has attracted the most interest in the scientific community in recent years (Zanarini, et al., 2004). Thus far, the treatment that has obtained the most empirical support is Dialectical-Behavioral Therapy (DBT) (Linehan, 1993). However, despite the weight and responsibility that falls on family members, psychological treatments for BPD patients do not usually include their relatives (Glick & Loraas, 2001; Harman & Walso, 2001; Hoffman, et al, 2005). In this regard, it is worth pointing out how difficult it is for family members to coexist with BPD patients. In fact, they report feeling incapable of dealing with the problems of their loved ones. Giffin (2008) found that parents of daughters with BPD manifest chronic and traumatic stress, as well as feelings of guilt, social isolation, and exhaustion due to lack of sleep. Regalado (2011) observed that 95.3% of family members present some degree of overload, as well as somatic symptoms, depression, anxiety, obsessions and compulsions, paranoid ideation, and other clinical symptoms, and these results coincide with those found by Schiers and Bok (2007). These symptoms are greater in people whose relative with BPD has attempted suicide, and lack of appetite, sleep problems, guilt, and thoughts of death have also been observed. Along the same lines, Goodman (2011) found that 88% of relatives of patients with BPD perceive that their emotional health is severely affected, with this being the most impaired dimension, although they also present problems related to their physical health, work, and interpersonal relationships. Other studies have found that family members often experience severe forms of psychopathology (Gunderson & Lyoo, 1996). To this complex situation, another aspect should be added, the stigma that surrounds this disorder. This stigma is observable not only in the general population, but also in some mental health professionals, who often refuse to care for this type of patient (Hoffman et al., 2005).
In a recent systematic review of interventions for BPD relatives, Guillén et al. (2020) describe the interventions created so far. Initially, some of these programs included the family in one or two sessions to give them guidelines for helping the patients (Blum, et al, 2002; Rathus & Miller, 2002). Other programs included both patients and family members, with the treatment administered jointly (Santisteban et al, 2015; Santisteban, et al, 2003). However, in both cases, the focus is on the BPD patient. Nevertheless, currently, there are programs where the treatment focuses exclusively on relatives of patients with BPD. Some of them present a psychoeducational format (Grenyer et al., 2018; Pearce et al., 2017), whereas others focus on skills training, either based on mentalization (Bateman & Fonagy, 2018) or on DBT skills (Hoffman et al., 2005, 2007). The program that has obtained the most empirical support so far is Family Connections (Flynn et al., 2017; Hoffman et al., 2005, 2007), which is based on DBT skills training and aims to create a validating family environment to deal with the constant ongoing crises (Liljedahl et al., 2019).
From our point of view, the fact that several specific programs have been developed for these families is a sign of progress. However, it is curious that, although evidence-based treatments for BPD relatives are already available, few studies have focused on obtaining information about the clinical and personal situation of family members of people with BPD. To date, the scientific literature on the topic suggests that relatives may lack the necessary skills to effectively help their loved ones (Flynn, et al., 2017; Fruzzetti, 2005; Hoffman et al., 2005; Hoffman et al., 2007; Wilks, et al., 2016). Other studies analyze the existence of clinical symptomatology in relatives of people with BPD, and they propose that this symptomatology may have contributed to the origin or maintenance of the BPD problem (Bailey & Grenyer, 2014; Ruocco, et al., 2015; Santisteban et al., 2003; Scheirs & Bok, 2011; Torgersen et al., 2000).
The first proposal highlights relatives’ difficulties and lack of skills in dealing with crises, emergency room visits, interpersonal conflicts, self-harm, or suicide attempts. Several studies point out that family members experience feelings of guilt, confusion, ignorance, incompetence (Buteau, et al., 2008), depression, anxiety, and grief (Hoffman, 1998; Hoffman, et al., 1999). This approach also emphasizes BPD patients’ difficulties in communicating and managing their emotions effectively, and the fact that, in conflict situations, the family environment manages to invalidate the person with BPD (Miller & Skerven, 2017). Consequently, a vicious circle often occurs where people who are invalidated in a generalized way do not learn emotional skills and often end up mislabeling their emotions, expressing them incorrectly, and invalidating themselves, while other people perceive them as chaotic, unpredictable, and emotionally intense, which leads to further invalidation (Fruzzetti, et al., 2005).
The second proposal points out that the presence of psychological problems in family members may heighten the patient’s vulnerability. These studies show that genetic vulnerability and patients’ early negative experiences may increase the risk of developing BPD in adulthood (Steele et al, 2020). In this line, some studies analyze the stress associated with caring for people with severe mental illness (Baronet, 1999; Harvey, et al., 2001; Liu et al., 2007; Ostman & Hansson, 2004; Tsang, et al., 2003; Veltman, et al., 2002), finding that an environment with high emotional expression can worsen the patient’s psychopathology. In line with conflictive and unstructured family settings, Bandelow et al. (2005) showed not only a greater number of conflicts within the BPD family nucleus, but also a greater amount of mental illness among the parents, which would negatively influence the relationship and the maladaptive behaviors learned by their children.
Therefore, the relationships and directionality among the different factors are not clear. However, given the importance of the family environment in the development and maintenance of BPD, we consider it relevant to examine this aspect more in depth. Thus, the aim of this study is to analyze the clinical situation of a sample of relatives of people with BPD and compare it to a sample of relatives of the general population in order to find out whether there are differences between the two on a number of relevant variables, such as depressive and anxious symptomatology, emotional expression, and quality of life. The second aim is to study whether there are differences in dysfunctional personality traits between the two samples and analyze whether PDs exist in the sample of relatives of patients with BPD.