The Trials of Borderline Personality Disorder

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Borderline Personality Disorder (BPD) is a psychological illness characterized by mood swings and abrupt changes in behavior. Although it is indeed a serious disorder, it has been highly stigmatized, primarily due to extreme depictions in mass media, such as Glenn Close’s character in the movie Fatal Attraction. To set the record straight: people suffering from BPD are not knife-wielding psychopaths intent on finishing off anyone who gets in their way. However, the inconsistent emotional and behavioral features of the disorder can make daily functioning difficult. As a result, BPD often interferes with the formation and maintenance of long-term relationships as well as a stable self-image. Because of the severity of certain symptoms (e.g., suicidality), treatment is frequently aimed at symptom management rather than an overall cure.

Signs and Symptoms

The following are signs and symptoms of Borderline Personality Disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) states that you need five of its criteria to be officially diagnosed with the disorder. Please note that some of the signs and symptoms discussed below are not officially part of the DSM-5 criteria but are common to the disorder.

Efforts to Avoid Abandonment

People with BPD often have a fear of abandonment. As a result, they will do almost anything to avoid it. For example, a person may say that they are going to hurt themselves if their partner attempts to break up with them. The abandonment may not even be real but, because of their concern, they act to put off any possibility it could occur.

All or Nothing Thinking

This pertains to a person’s view of themselves and their relationships. It is not uncommon for a person with BPD to have rapidly changing views. They may act as if they love someone one minute and hate them the next. Their self-image may also be rapidly shifting from positive to negative. This rapidly changing view, plus the fear of abandonment, makes it difficult to trust other people and lends doubt to their intentions. As a result, their ability to maintain meaningful relationships is compromised. It is not uncommon for someone with BPD to engage in intense relationships only to see them quickly flame out.

Impulsive Behavior

This type of behavior is frequently seen as reckless and self-sabotaging. People with BPD may act for immediate gratification without thinking through the consequences of their actions. Some areas of impulsivity include shopping sprees, binge-eating, drug use, and promiscuous sex.

Anger

Episodes of intense angry feelings are often displayed through verbal and physical altercations. These angry feelings often do not appear appropriate for the situation. Another person may wonder: “where did that come from?”

Emotional Instability and Sensitivity

Besides anger, people with BPD may exhibit extreme shifts in emotions involving sadness and anxiety, none of which appear to remain stable for a long period of time. This is particularly frustrating in a population that frequently lacks security in their work and living situations, and has difficulty finding a healthy balance. People with BPD are frequently seen as sensitive. They may have extreme emotional and behavioral reactions to situations other people would perceive as minor. You might find people wondering: ”what’s the big deal?”

Emptiness

Many times you will hear someone with BPD describe a feeling of emptiness. This is intertwined with periods of intense emotion.

Suicidality

One of the most severe symptoms of BPD is suicidality. This can range in severity from suicidal ideation to actual attempts. Up to 75 percent of people with BPD will make a suicide attempt during their lifetime and are more likely to die as a result when compared to any other psychiatric disorder.

Self-Harming Behavior

Although self-harming behavior is a serious concern it does not mean someone is suicidal. People with BPD frequently self-harm in an attempt to feel better. Physical pain often distracts one from more severe emotional distress. Self-harming behavior may include cutting and burning.

Dissociation

People who suffer from dissociation feel disconnected from their bodies. They may also describe being cut off from reality.

Job Instability

It may not be surprising to find that many people with BPD have difficulty finding and maintaining employment. Employers generally do not want to hire people who display rapidly changing emotional and behavioral states. The instability of the disease makes it difficult for people to put in the consistent quality effort usually required in the workplace. Further, relationship issues with coworkers may cause conflict and lead to complaints and ultimate dismissal. What’s more, the goals and desires of people with BPD often shift, making it difficult to choose and follow through on a specific career.

Prevalence/Course

It has been estimated that 1.6% of the population currently has BPD and almost six percent will have the disorder at some point in their lifetime. Although professionals are generally reluctant to diagnose a personality disorder in minors, there is evidence to suggest that the onset of BPD often occurs before the age of 18.

Despite its reputation, having BPD does not mean a life of dysfunction and misery. In general, symptoms decrease in severity as one ages. Many people experience complete remission of the disease and can, with treatment, lead functional and happy lives. Even those people that do not experience remission are frequently able to manage their most severe symptoms and achieve adequate functionality. Unfortunately, remission of symptoms is not always lasting and some never experience any significant relief from their problems. Younger people tend to have the most severe symptoms (i.e. suicidal behavior) but older people may possess symptoms, while less severe, that still linger into later adulthood.

Possible Causes

The exact etiology of BPD is unknown, but the following areas have been posited as possible causes:

Genetics

There appears to be a moderate genetic component to BPD. Research has shown that over 50% of people with BPD have a close relative with the disorder. Thus, heredity is a significant risk factor for the development of BPD.

The Brain

Scientists have studied the brains of people with BPD and found some characteristics that are consistent across subjects. First, people with BPD appear unable to activate the parts of the brain that are integral to emotion regulation. In a related vein, brain function of the amygdala and hippocampus, which are related to emotion and behavior, appear to be diminished. This could partially explain why those with BPD are seen as emotionally reactive.

Additionally, there are indications that individuals with BPD have less gray matter when compared to people without the disorder. Gray matter has been implicated in the processing of emotions, decision-making, and self-control. Further, research has shown that people with BPD perceive negative emotions to neutral faces more so than others. Whereas another study reported that individuals with BPD exhibited a brain abnormality in the anterior insula, a part of the brain involved with perceiving information. In particular, that part of the brain did not activate when compared to adults without BPD. Taken together, this might shed light on why people with BPD frequently misinterpret or misunderstand the actions of others, leading to more extreme responses than are appropriate.

Environmental Factors

For many years, BPD has been associated with childhood trauma and a lack of stable relationships. This may include physical and sexual abuse, neglect, chronic fear, and poor parenting practices. It is easy to see how a child’s upbringing can lead to attachment difficulties and fears of abandonment. Of course, not every child with a traumatic background develops BPD. Scientists, such as Peter Fonagy and Anthony Bateman, as well as Marsha Linehan, have suggested that BPD is due to both environmental and biological causes paired with an inability to exhibit effective coping mechanisms.

Diagnosis

The diagnosis of BPD can be problematic. First, professionals may be reluctant to diagnose it due to its associated stigma, especially with younger populations. Second, its symptomatology can make it look like other disorders. For example, mood swings could appear to be what you would find in Bipolar Disorder. Besides these symptoms can often be severe enough to diagnose co-morbid disorders. Over 80% of people with BPD can be diagnosed with other mood or anxiety disorders. Taken all together, forming a differential diagnosis is complicated at best.

Luckily, there are assessment measures that have been found to have good reliability and validity in diagnosing BPD. Some of the major personality inventories, namely the Minnesota Multiphasic Personality Inventory (MMPI) and the Millon Clinical Multiaxial Inventory (MCMI), have scales that measure Borderline Personality Disorder. Moreover, there are multiple specific screening measures for BPD with good psychometric properties, including the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), and the Five- Factor Borderline Inventory (FFBI). In addition to these assessment devices, clinicians often rely on structured and unstructured interviews. Taken together, there are more resources than ever to accurately diagnose BPD.

Treatments

The treatment of BPD has come a long way in the past 30 years. Third wave therapies, such as Dialectical Behavior Therapy (DBT), have made great strides in helping alleviate the condition. However, due to high rates of comorbidity and shifting client emotions, treatment can be challenging.

Psychotherapy

Psychotherapy is the front-line treatment for BPD. Although many types of therapy may be used to treat BPD, four therapies have come to the forefront as most effective:

Dialectical Behavior Therapy (DBT)

DBT, developed by Marsha Linehan, was one of the first therapies designed specifically for the BPD population. DBT is an offshoot of Cognitive Behavioral Therapy, but it has a strong focus on skills that promote conflict resolution, distress tolerance, and emotion regulation. A full complement of DBT offers individual and group therapy with additional out of session consultation and coaching.

Schema-Focused Therapy (SFT)

Schema-Focused Therapy focuses on changing four schemas that are theorized to contribute to BPD: detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. The therapist is encouraged to form a parental-like attachment to the client in an effort to change maladaptive thoughts, feelings, and behavior related to previous negative attachments.

Transference-Focused Therapy (TFP)

Transference-Focused Therapy is based on the psychodynamic principle of transference. In short, therapists use their relationship with the client to learn about the issues that contribute to an individual’s interpersonal behavior. Then the therapist helps the client adopt more adaptive behavior to improve their relationships. Unlike other therapies that treat BPD, there is usually no group component.

Mentalization-Based Therapy (MBT)

Mentalizing refers to one’s ability to imagine and understand the thoughts and feelings of others as well as yourself. It is posited that a lack of mentalizing is what leads to personal interaction problems frequently experienced by people with BPD. Through individual and group therapy, therapists aim to improve a client’s ability to mentalize and react appropriately to interpersonal situations.

Medication

There is currently no medication authorized by the FDA specifically for the treatment of BPD. Instead, medication is used for specific symptoms. For example, an anti-depressant, such as a serotonin specific reuptake inhibitor (SSRI) may be prescribed to help alleviate depressive symptoms. 

Challenges of BPD Treatment

  • When dealing with co-morbid diagnoses, one question is which disorder should be the primary focus of treatment. For instance, for someone with BPD and a co-morbid substance abuse problem, do you focus on treatment for BPD or substance abuse? If you focus on BPD, a substance abuse issue may confound the effectiveness of treatment and vice versa.
  • Another problem with treatment for individuals with BPD is the client’s unwillingness to stick with treatment. Due to the strict limits put on clients by certain types of treatment, the client may choose to leave treatment rather than deal with the consequences. For example, in DBT, a client may be restricted from therapist contact for some time due to perceived manipulative behavior. Moreover, a client may turn on their therapist as they turn on other people in their life. One day they may decide they no longer like their therapist and may want to move on.
  • Treatment for BPD does not always go as planned. Because suicidality and comorbidity are often present, outpatient treatment may be interrupted by inpatient hospitalization, partial hospitalization, or residential treatment.

Although there are workbooks available that can help someone with BPD work on their treatment issues, it is a difficult condition to remedy without professional help. However, with proper treatment, many symptoms can be reduced, if not altogether remitted. If you or a loved one has multiple signs/symptoms of BPD, it is critical to find a therapist who has experience in treating the disorder.

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MS Broudy is a psychologist, writer, and consultant. He has a Ph.D. in Clinical Psychology and a master’s degree in Social Psychology. He has spent over 20 years providing therapy and assessment services for a diverse set of clients. MS specializes in writing about mental health, parenting, and wellness. He has his own blog, mentalspokes.com, where he writes about psychological issues.
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