Personality Disorders 102: Borderline PD

I’ve used the word “controversial” quite often when talking about the personality disorders, and not without reason. Today’s topic, Borderline Personality Disorder, is the pinnacle of debate amongst the PD’s, and probably the third most argued-about psychiatric disorder ever. (First and second places would go to Dissociative Identity Disorder and ADHD/ADD respectively, which both have pretty interesting histories).

Borderline Personality Disorder is in Cluster B, which is sometimes called the “dramatic” or “emotional” cluster. This is fitting, as the core symptom in BPD is the person’s emotions: emotions are stronger and more intensely-felt than those of a typical person, and their overwhelming and changeable nature causes the majority of the other symptoms.The criteria for BPD are listed as:

The criteria for BPD are listed as:

  • Frantic efforts to avoid real or imagined abandonment.
  • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. This is called “splitting.”
  • Identity disturbance: markedly and persistently unstable self-image or sense of self.
  • Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  • 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).
  • Chronic feelings of emptiness.
  • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  • Transient, stress-related paranoid ideation or severe dissociative symptoms.

Put more simply: someone with BPD will have very intense reactions to pretty much everything- their moods; opinion of themselves; opinion of other people; and their level of safety, can all change wildly in moments. These mood swings may sometimes look like  Bipolar disorder, but there are two ways to tell bipolar disorder and BPD apart.

Unlike the general media view, the mood states of the average person with Bipolar disorder last for weeks or months, while in someone with BPD they will last for a few hours, or sometimes even a few minutes. (However, there are subtypes of Bipolar that have quicker changes- ultrarapid BP tends to change every few days, while ultraradian BP can change within a day).

Also, mood changes in Bipolar Disorder are occasionally influenced by external stimuli, but are almost never caused by them, while mood changes in BPD are almost always linked to or caused by a event, even if it is an incredibly minor one. Someone who was fired from their job while in a manic state would remain in a manic state, and probably not care about the job at all until after the mania receded. Someone with BPD would instantly feel deeply depressed if they lost their job, and perhaps overwhelmed by fears and self-loathing for being fired. But the feelings may not necessarily last very long; if something good happened later on that day, a temporary extreme happiness would be possible.

A major trait of BPD is a cognitive distortion (an error in thought patterns) known as “black-and-white-thinking” or “splitting”. As children first learn to form opinions on their situations and create categories to put things in, things can only be in one category or its opposite, and there isn’t really anything inbetween.  If they categorise an activity as “fun”, it must be completely fun: at the moment it stops being as fun, it is therefore categorised as “completely boring”. As their thinking matures, they learn that situations cannot generally be organised in this way, and they understand the variations and grey areas present in everything.

For someone with BPD, on the other hand, this ability to see between the extremes does not develop in the same way. Someone with BPD will be very changeable in how they see themselves and the people close to them. For example, they may idealise their friends, believing them to be amazing people who cannot do wrong. When one of the friends then does something wrong; whether this is an actual injustice , or simply something that doesn’t match their idealised view, the person with BPD will be unable to understand how someone they viewed as “all-good” could do something “bad”.

The person with BPD, depending on their temperament and circumstances, can mainly react in one of two ways.  They could see this as a deliberate misleading by the friend, and feel like they have been lied to- they would then devalue  the friend, meaning they would temporarily switch to hating them and seeing them as “all-bad”. Or, they could see this as a failure on their part, either for trusting someone who they shouldn’t have or for holding people to a standard they couldn’t reach. In this case, the person with BPD would then continue to idealise the friend, and instead devalue themselves, viewing themselves as a wholly-bad person who doesn’t deserve their wholly-good friends.

Someone with BPD who takes the devaluing others reaction, and externalises (shows outwardly) these changes in opinion, is likely to have difficulties with keeping friends, as it can be difficult to deal with someone who is liable to hate you at any moment. However, people with BPD who tend to react by devaluing themselves do not have as many difficulties- even people close to them may not be aware this cycle happens.

Other symptoms interlinked with this difficulty with keeping relationships are a deep-seated fear of abandonment, and a missing or fuzzy sense of self. Because someone with BPD finds it hard to keep a consistent sense of who they are, they may attempt to obtain one through the people they are with i.e. they may only be able to feel like a “real” person when they are in a relationship, because the other person’s view of them gives them something to work with.

People with BPD struggle to know where the boundaries are between themselves and others…. if they are alone, even for a few minutes, they may feel like they are completely and utterly alone. However, if they are incredibly close to someone, they may start to feel like they have lost themselves, that they and the other person are meshing into each other. This causes a sense of panic that can lead them to push people away out of fear of being too tightly linked, then try to pull them back from feeling like they don’t exist if they’re on their own… a cycle that can make romantic relationships turbulent.

An important thing to understand in all of this is that the person with BPD is not attention-seeking or deliberately over-reacting in this.One of the most damaging stereotypes about BPD is that people with it are manipulative, which is not true.Also, if things are particularly stressful/difficult, a person with BPD may react by dissociating: in that state they may have very limited control over their reactions.People with BPD, due to how overwhelming their emotions usually feel, often turn to self-destructive and/or impulsive behaviour to either remove or overpower their feelings.

People with BPD, due to how overwhelming their emotions usually feel, often turn to self-destructive and/or impulsive behaviour to either remove or overpower their feelings.This can be outwardly-focused; such as reckless driving; excessive spending; and minor criminal behaviours. It may also be inwardly-focused; such as self-harming and suicidal fantasies or attempts. Indeed, it is estimated that 70% of BPD sufferers have attempted suicide (usually impulsively),  while 10% complete it. That statistic, while depressing, does not give the full story. For many people with BPD, the late teens and twenties are very difficult. However, once those decades have been navigated through, later life appears to get easier, and many people will not fit the diagnostic criteria of BPD by the time they are middle-aged:  a 2011 study on how people with BPD fare over time compared to people with other disorders showed that almost all of the people with BPD (88%) got better over time.

BPD is kind of a psychopharmalogical rarity, in that it is relatively unaffected by medications: while medications are prescribed to deal with associated symptoms such as depression (and sometimes impulsivity, if it is extreme), there is no medication specifically for BPD. The most effective current treatment is Dialectical Behaviour Therapy (dialectic means “a reasoned resolution of conflict”). DBT was developed by psychotherapist Marsha Linehan, herself diagnosed with BPD, and combines cognitive-behavioural therapy, mindfulness, and the practice of emotional regulation skills.

Psychological Criticisms of BPD

Unlike in the other posts in this series,  I haven’t included any fictional examples of people with BPD. That’s because there aren’t really any good examples. The closest I can find is the title character of Girl, Interrupted– the film is based on a memoir of someone with BPD, but the film itself doesn’t show BPD in much detail beyond depression and self-injurious behaviour.

BPD is the only mental disorder that includes self-injurious/suicidal behaviour in the diagnostic criteria. Therefore, some researchers have shown that people can be diagnosed with BPD just because they self-injure, regardless of whether other criteria fit. (i.e. Herpertz found that in a sample of people diagnosed with BPD, only 28% still fit the criteria if self-injurious behaviour wasn’t counted.) Similarly, others have argued that because people with BPD can be very difficult to treat, the diagnosis can be applied as a catch-all to any patient who is difficult to treat.

This over-application of the diagnosis is particularly important in the case of BPD, due to the often negative stigma it can receive: it can be viewed negatively in psychiatry as before the advent of DBT it was regarded as untreatable, and because there is little medical management. Also, when researching BPD online, there are many places on the internet that regard people with BPD incredibly negatively, another factor that is probably linked to why there are so few media examples.

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