Today’s topic, Borderline Personality Disorder, is perhaps the third most argued-about psychiatric disorder (with first and second place going to Dissociative Identity Disorder and ADHD/ADD).
One of the many contentious points is its name. When the DSM was first developed during the 1950s, psychiatrists divided mental health issues into “neurotic” and “psychotic”. People with “neurotic” illnesses were in distress but still aware of reality and that they were ill, while people with “psychotic” illnesses were detached from reality and often unaware that they were ill. Borderline personality disorder received its name because psychiatrists saw the symptoms as being on the border of both categories. However, that method of categorising mental health conditions is no longer used, so “borderline” now doesn’t mean anything. It can also be actively unhelpful, because people can assume it means that someone is on the border of having a mental health condition and not having one. The ICD-10 instead uses the name “Emotionally Unstable Personality Disorder”, which better reflects the condition’s core symptom.
A person with EUPD experiences much more intense and changeable emotions than a typical person, and the overwhelming nature of those emotions underpins the other EUPD symptoms. To be diagnosed with EUPD in the DSM-5, someone must meet 5 of the 9 criteria:
- They compulsively focus on avoiding real or imagined abandonment by others
- They have unstable and intense relationships where they alternate between idealizing and demonising others. (This pattern is known as “splitting”)
- They have a continuously unstable self-image or sense of self
- They are very impulsive in multiple ways which can all be personally harmful, such as spending, sex, substance abuse, reckless driving or binge eating
- They often express suicidal intentions or self-harming behaviour, or they frequently threaten suicide
- They have unstable moods caused by reactions to events, such as intense episodes of sadness, irritability, or anxiety which typically last for a few hours
- They chronically feel empty or like they are missing something essential
- They have inappropriate and intense anger, which they struggle to control. Someone may frequently lose their temper, seem constantly angry or get into physical fights
- They experience short-term paranoia or severe dissociation when under stress
The standard personality disorder criteria must also apply. “A person needs to have a collection of unusual behaviours and traits which affect a large portion of their everyday life. Those behaviours and traits must start before early adulthood. They need to cause negative consequences for the person, who should be upset by or annoyed at those behaviours.”
For someone with EUPD, every perception is both intense and highly variable. A person’s mood, understanding of themselves, opinion of other people, and level of safety can change wildly in moments. Because of how overwhelming emotions feel for someone with EUPD, they may rely on self-destructive or impulsive behaviour to remove or overpower their feelings. This can be outwardly-focused behaviour such such as reckless driving, excessive spending, or minor crimes. It can also be inwardly-focused behaviour such as self-harming or suicidal fantasies or attempts.
A major trait of EUPD is black-and-white-thinking or “splitting”. As children develop, they go from sorting objects in binaries- good/bad; fun/boring; friend/enemy – to learning how to integrate conflicting experiences into a complex whole. People with EUPD struggle to carry out this integrating process, and continue thinking in extremes. People and situations are alternately good or bad/ right or wrong/ loved or hated, with little neutral ground.
This pattern is likely to be strongest within friendships and relationships. Someone with EUPD can easily idealise a friend or partner, and see them as a perfect person who cannot do wrong. When the idealised person does something wrong – either an actual injustice, or an action which doesn’t fit their perfect status – a person with EUPD will struggle to understand how someone “all-good” could do something “bad”. They might feel like their friend/partner deliberately deceived them, and instinctively switch to devaluing the partner (perceiving only the person’s negative traits, and recalling only past disagreements rather than good memories). Alternately, the person with EUPD may blame themselves for trusting mistakenly, or for holding people to a standard they couldn’t reach. In this case, they may continue to idealise the friend/partner and instead devalue themselves.
If someone with EUPD frequently and publicly devalues others, they will experience difficulties in maintaining relationships as a result. However, people who react by devaluing themselves will probably have fewer difficulties, as people close to them may not even be aware of this process. Also, because people with EUPD can struggle to keep a consistent sense of who they are, they may rely heavily on relationships to fill in the gaps; they many only be able to form a self-image by using their partner’s opinion of them as a foundation. Because of this, breakups can cause severe distress for someone with EUPD.
One estimate suggests that 70% of people with EUPD attempt suicide (usually impulsively), while 10% complete it. That saddening statistic is thankfully not the full story. Although young adulthood and early adulthood are incredibly turbulent for people with EUPD, later life becomes easier. In one 2011 study, 88% of the people with EUPD reached remission (>50% reduction in symptoms) within 10 years of their original diagnosis.
Although medications can help with associated issues such as depression, no medication specifically helps EUPD. The most effective treatment is Dialectical Behaviour Therapy, which combines cognitive-behavioural therapy, mindfulness, and emotion-regulation skills. This approach was developed by psychotherapist Marsha Linehan, who has been diagnosed with EUPD. Another approach, Mentalisation-Based Therapy, focuses on teaching people to recognise the connections between emotions, behaviours and perceptions.
In media, EUPD has limited representation. Even Girl, Interrupted, which is based on a memoir by someone with EUPD, includes few of its traits beyond self-injury. This may be due to the film Fatal Attraction, which accidentally created a cultural association between EUPD and danger through its possessive, violent character Alex. However, 2015-2018 series Crazy Ex-Girlfriend features a sympathetic protagonist with EUPD (called BPD within the show), and it has recieved positive feedback for protagonist Rebecca’s portrayal and for specifically naming her diagnosis.
Although all characters with confirmed EUPD have been female, some researchers have discussed how Anakin Skywalker from the Star Wars series demonstrates most EUPD criteria. (Unfortunately, these studies are not openly-accessible.)
One complication with showing EUPD in media is that its most visible symptom- intense and variable moods- is already mis-represented by media portrayals of bipolar disorder. Most people with bipolar disorder experience each phase of depression, mania, hypomania or stability for weeks/months, and mood changes are completely independent of external events (Although faster-cycling subtypes of bipolar disorder do exist, they account for a tiny percentage of cases). However, media examples of bipolar disorder tend to show characters who experience short-term mood shifts in response to events. This is unfortunate for both people with bipolar disorder, who are given ineffective representation, and people with BPD, who see their chances of potential representation mislabelled.
Psychological Criticisms of EUPD
EUPD is the only mental health condition which includes self-injurious or suicidal behaviour as a diagnostic criterion. As a result, people who self-injure can be diagnosed with EUPD even if the other criteria do not fit well. In one study of people previously diagnosed with EUPD, only 28% still met the diagnostic criteria if self-inury was ignored. This suggests that some EUPD diagnoses are used as a tool to obtain medical help for someone who self-injures, rather than as the most appropriate diagnosis.
Over-applying a diagnosis is particularly worrying in the case of EUPD due to the negative feedback it can often receive. EUPD can be viewed negatively within psychiatry, possibly because it was historically considered untreatable, and still has limited medical treatments. Others have argued that because people with EUPD can be very difficult to treat, the diagnosis can be applied as a catch-all to patients who are have not responded to pevious treatment or who have complex mental health needs. Some people diagnosed with BPD have found that the standard of medical care or support available is reduced or even removed following a BPD diagnosis. The combination of over-applying and simultaneously stigmatising a diagnosis causes unnecessary harm and risks leaving people without the appropriate treatment or tools.