Insights into Psychology

What Is… Borderline Personality Disorder

Borderline personality disorder symptoms

In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is borderline personality disorder.

I’ve contemplated writing this post for a while, and was somewhat reluctant because there are quite a few bloggers out there with borderline personality disorder (BPD), who can certainly tell it a lot better than I can. However, I’ve been covering other personality disorders, and BPD isn’t a gap that I want to leave. So, let’s dive in.

According to the Merck Manual, “Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations, and impulsivity.”

BPD is part of the DSM-5‘s cluster B of dramatic/emotional/erratic personality disorders. The term borderline came about because the condition seemed to border on a number of other conditions. The International Classification fo Diseases 10th edition (ICD-10) used the term emotionally unstable personality disorder (EUPD).

Symptoms

As with any personality disorder, it’s normal for anyone to display some of these symptoms some of the time. A personality disorder is only diagnosed when the symptoms are pervasive, relatively consistent across time and contexts, clearly established by the start of adulthood, and cause significant distress and/or impairment in functioning.

Borderline personality disorder symptoms include:

  • a persistent pattern of instability in relationships, self-image, and emotions, with marked impulsivity
  • desperate efforts to avoid real or perceived abandonment, which is intensely feared
  • unstable, intense relationships with splitting, i.e. alternating between idealizing and devaluing
  • instability in self-image or sense of self
  • impulsivity in at least 2 areas that could potentially be harmful
  • “Repeated suicidal behavior, gestures, or threats or self-mutilation”
  • rapid mood fluctuations, often within the space of a few hours
  • persistent feelings of emptiness inside
  • periods of intense anger and angry outbursts, often experiencing shame afterwards
  • paranoia or dissociation under severe stress

Non-suicidal self-injury, i.e. self-harm, may be a way of regulating emotions or relieving feelings of numbness. Suicidal gestures are attempts where the intent is not to die, but to demonstrate that one’s pain is severe enough that they need help. While there is often not lethal intent, 8-10% of people with BPD eventually die by suicide.

Other characteristics

BPD is most often misdiagnosed as bipolar disorder. It can coexist with other personality disorders, including other cluster B disorders, but key differentiating factors from narcissistic PD and histrionic PD are that people with BPD see themselves negatively and feel empty inside.

The estimated prevalence is about 2-6% in the general population. When you look at psychiatric inpatients, about 20% have BPD. It’s more common in females (about 75% of people with BPD are female), although it’s hard to say how much of that is bias in diagnosing.

It’s common for people with BPD to have a history of childhood abuse or neglect, but that’s not always the case. There’s also a heritable component, with a five-fold risk increase when a first-degree relative has the disorder. DBT founder Marsha Linehan has proposed a biosocial model in which BPD arises from interactions between innate vulnerability and environmental factors.

Treatment

Medications can play a role in managing some of the symptoms (I’ve done a post on meds for BPD here), but therapy is the primary form of treatment. Options include:

  • dialectical behaviour therapy (DBT)
  • systems training for emotional predictibility and problem-solving (STEPPS), a CBT-based therapy
  • mentalization-based treatment (MBT)
  • transference-focused psychotherapy (TFP) – based on psychodynamic psychotherapy
  • schema-focused psychotherapy

Stigma

Borderline personality disorder is incredibly stigmatized, both by the world and large and by the health care field. It was certainly something I saw a lot during the 15 years I worked in mental health. I think it was largely a combination of lack of understanding and lack of skills. BPD can produce behaviours that look manipulative if you can’t recognize that they’re attempts, however maladaptive, to meet underlying needs.

Being therapeutically effective with BPD takes a skill set that a lot of people who aren’t specially trained just don’t have, but I think that instead of taking responsibility for their own lack of skills, mental health professionals too often end up blaming the patient. I’ve found that people with BPD are often very perceptive, and when they’re faced with BS from a health care provider, they can be adept at poking at exactly the spot where that provider feels vulnerable. That stirs up all kinds of countertransference on the clinician’s part, and everything falls apart.

I suspect there would be less stigma if there was more available, accessible, effective treatment. The world of mental health care really needs to do better.

Does anyone have any thoughts on why BPD is so stigmatized?

Source

The Psychology Corner: Insights into psychology and psychological tests

The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.

58 thoughts on “What Is… Borderline Personality Disorder”

  1. Interesting info! What’s funny/sad is that my genius ex husband “diagnosed” me with this and gave a book about it to my daughters to read so they could understand what a crazy person I was. A few pages in and they both realized it described him not me…

  2. Does anyone have any thoughts on why BPD is so stigmatized? Yeah, I do . I grew up (in part, because part of the time I was in foster care) with a mother who had BPD. It was exquisitely painful. Nobody recognized her problem (they diagnosed her as schizophrenic at one point), and it was only after her death that a sibling of mine and me, researching our family history figured it out. There’s little information on BPD (or was) which, to me, is one reason for the stigma.

    A second and larger reason (in my opinion) is that people with BPD act out and may be perceived by others as truly loony. They can seem angry, mean and they are masters (I have first had experience of this) at tearing someone they’re angry at to shreds verbally and perhaps physically (my mother was too frail physically to do that though). All that emotional turmoil tends to alienate people. BPD people (again I have first hand experience) are very very lonely, but you’d never get someone with the condition to admit that.

    I have BPD. It’s acquired. Exposure to my mother during formative years probably initiated the process, but the trauma I underwent by being in foster care solidified the condition. It’s been gradual too, I would never have thought I had it, but all the boxes on the list you helpfully provided are ticked. All of them.

    You helped me today to understand why I keep having trouble finding therapists I trust and can associate with long-term. My current therapist isn’t working out, maybe for some of the reasons you gave, or I don’t know. I do know I don’t trust her anymore and that means the relationship is doomed. Another thing about BPD is that the person with the disorder doesn’t trust anyone, even themselves. It’s a way of protecting oneself from being hurt by being abandoned or for other reasons I suppose. I always thought I was just overly guarded because of the childhood trauma.

    As an adult though, I am finding that I have an increasingly difficult time with stress and abandonment issues are one of the larger parts of my mental illness.

    I hope that answered your question a little bit.

    1. It’s unfortunate that so many people end up going undiagnosed or being brushed off entirely by health professionals, because if they actually got appropriate treatment, it could be so much easier for everyone involved, including family members.

  3. Stigma: Involuntary institutionalization, paternalism/misogyny. Those are our guesses based on very limited information (see _girl, interrupted_ (winona ryder).

    Even though we’ve had very little success with it, we think marsha’s dbt is among the most important Care documents ever written and wish it were called Life Manual and taught starting in kindergarten

  4. I was once diagnosed with BPD, years ago. Eventually, I was told (after A LOT of therapy) that I no longer met the criteria. Sometimes I wonder if it’s so stigmatized because of the name itself. And the “personality” aspect of it… I wonder if people see it as the sufferer’s fault. I’m not sure.

    1. I think they need to revamp the whole personality disorder concept. Changing the wording isn’t going to make the stigma go away entirely, but personality disorder is pretty blame-y.

  5. My brother suffers with BPD and it’s a bit scary. He doesn’t want help so we can only do so much. He has trouble with substance abuse and has threatened suicide and also disappeared for days at a time. He ignores calls so you fear the worst. Lately, he’s been staying with my parents so at least we know he’s safe for now.

  6. Excellent post Ashley!

    Really well researched and balanced.

    Sorry this is going to be a bit of a long comment…

    Just my cents here from someone with diagnosed BPD.

    BPD I feel is stigmatised for a variety of reasons.

    The media likes to either glamorise or make out that people with these disorders are stalkers, untrustworthy, manipulative etc and it is understandable. Because some could well be if they do not seek appropriate help.
    But the trouble is the media presents a type of person, people watch it and then think that is all BPD’s in the world. Aka “gone girl” and “basic instinct”

    You explained brilliantly that it is very dependent on the type of skill set and understanding that the non-BPD has with them. We are generally very react-ive to outside stimuli…just like someone perhaps with autism may be with too much stimuli.

    If a person can look beyond the obvious and see what is “behind” the surface behaviours/moods then they will see that there are reasons why we mostly are so reactive to life and people in general. But it takes someone very perceptive and often patient to get this.

    Usually at some point in our lives we have suffered a combination of abuse and/or significant trauma and have basically developed coping mechanisms to deal with life and the people around us. Unfortunately though those mechanisms are often self-destructive and inappropriate. Imagine if you never disciplined or taught a child the “right” correct ways…that child would grow up thinking and feeling its behaviours were fine.

    Those with BPD are very child-like in their behaviours and ways they try to get their needs met simply because we were either not taught or were not given the chance to learn the appropriate ways in which to express ourselves or communicate effectively. Many of us need to be re-parented (to be our own parent so to speak), connect with our inner child… so we learn how to connect, trust, accept, view, love others and ourselves.

    Our environment and/or exoeriences made it so that we are kinda oversensitive, and over-reactive. We feel things on a much more intense and distressing level. We are in a lot of pain. And much of what we say, or do is because of pain and/or anger underneath.

    Many believe that it should be named ptsd/cptsd because there are a number of similarities.

    This is true. But some of us have that aswell as the BPD or on top of it like myself.

    I am not so sure how I feel about this only that those of us diagnosed with it will know that nothing probably made sense in our world until we were diagnosed with it. And the fact that anyone could make sense of our messed up world and the way we feel and think was truly like a miracle.

    There are many that stigmatise it because they simply have had a bad or damaging type experience/s with someone with it, and then (because of either lack of education or lack of understanding) just label the whole world of BPD’s bad/selfish etc people. They blanket the whole lot of us with their one brush. And as we all know, everyone is different. But people feel especially if they have been hurt by one of us that they have to protect themselves.

    As you rightly say though no matter how boisterous or confident or fiesty a person with BPD may “appear” to be, deep down inside we hate ourselves, and feel we cannot trust people, and this is projected onto people in various ways, often through control and manipulative means.

    Some are more self-aware of their thinking and behaviour than others, and therefore once aware, we can be taught better ways.

    Also there is the fact that many are and can show narcissistic traits, and this also complicates the issue with the whole cluster B thing because then people associate BPD with Narcissists then you understandably get a whole load of mis-interpreting and misunderstanding of what BPD actually is and how it affects people.

    It is a lot easier for people to believe that we are just vulnerable Narcissists and give us all a wide birth, than it is to get educated and learn the disorder, and try to see things from our worldview.

    Then there is the mental health field where many therapists too have also fallen into the trap of like you say…blaming the patient, and the transference issues…then further misunderstandings can and will happen.

    Therapists need to know that they can work with someone and and develop a mutual trust and feel they are not wasting their time and energy on someone that they feel may manipulate and run circles around them. Therefore if the therapist is inexperienced or is not used to dealing with such clients,then they are likely to react and take personally things said or perceived even within sessions.

    A counsellor or just a mental health therapist is not going to be able to cut it.

    We need experienced help and support. And the trouble is, in this world, often this type of therapist does not come cheap.

    1. It definitely does not come cheap. The city where I am has a publicly funded DBT program, but the wait list is forever and they’re super picky about who they’ll accept. I don’t know why the powers that be don’t realize that if you provide appropriate, effective therapy in the community for people with BPD, it could cut way down on the need for ER visits and admissions.

      1. I agree with you.

        If it wasn’t for my therapist lowering his price because I’m low income and am classed as long-term sick so in receipt of benefits, then I couldn’t afford him.

        But I had to go through a few therapists before I found this one. And it does make you feel like giving up.

        But not all are in it just for the money. Some generally do wish to help.

        The only other thing for those that cannot either find or afford a good therapist is using online resources like:

        https://www.drdfox.com/

        He specialises in BPD treatment and clients… and his book is really good. His videos on YouTube are very helpful too and he is very understanding of our issues.

        There are also many good books out there that can help. And this was what I was doing before, I had a few I was slowly going through…kind of self-therapy… that can help and make us feel validated and understood, which BPD’s need in bucket loads truly.

          1. Even once I found this one which was by accident (and does Online Therapy which I think is better nowadays)… I didn’t think it was going to work and neither did they, and we could not establish a good and strong enough therapeutic relationship that was consistent with a good enough framework.
            It has taken much work both sides and a determined effort to get where we are.
            What therapists need to realise is that we need a lot more time than perhaps the average client as trust is so very difficult.
            Unfortunately we do not make it easy for them with our natural defensive mechanisms in place.
            It takes work on our part too, to be willing to take our barriers down somewhat and let them in, something I didn’t really understand until I got to where I am today.

            But it takes a determined therapist too and one that really will go the extra mile so to speak.

            Both have to put a lot into the therapeutic relationship and know there will be pain involved. It is not an easy process. Anyone that says it is, is lying…

      1. Yeah it’s with all of the disorders and thing is it’s hard enough living with these disorders without added stigmatisation. Why is it that mental illness is still being demonised when it’s support we all need.

        1. And if there are things the media doesn’t understand, reach out and get a quote from a mental health organization. It really shouldn’t be difficult.

  7. Thanks for such a balanced post! I may have BPD or BPD traits (was diagnosed with it some years back but not sure I still meet the criteria). There is a lot of misinformation about personality disorders in general and them being called personality disorders, ie. character flaws, doesn’t help. I at one point had a personality disorder (DPD and BPD traits) label put on me just because my clinician wanted a reason to “prove” I was misusing care (which I don’t feel I was, but oh well), but she probably didn’t have the balls to diagnose me with factitious disorder.

    1. That’s really crappy on the part of that clinician. It’s so unprofessional when people let their own prejudice influence that labels that they decide to apply to patients.

  8. I would say that if you don’t feel it, you don’t feel it, end of story. Assuming for the sake of argument that the diagnosis is correct, it doesn’t mean that you’re necessarily going to experience every potential symptom.

  9. One of my very close friends received a diagnosis of BDP some years ago (and her story ended up a significant inspiration when I was writing my Annabelle story) and she was very scared by it. I think sometimes the stigma is one of the factors that has contributed to her not agreeing with the diagnosis, and fearing mental health practitioners.

    So…instead she has agreed to deal with one negative situation at a time. She has agreed to therapy at times when it was obvious that she was struggling, and has had a couple of short stays in hospital over the past few years.

    But she still finds it hard to hear anyone mention BDP, and she has not wanted to read anything about it.

    I feel for her so much. I love her dearly, but I have seen the distress she has experienced at times….and yes….the concern over her wellbeing is always there.

    1. I think it’s great that you incorporated that into Annabelle’s story. It’s such a difficult illness, and it’s the real human side of it that the world needs to see more of, not the stigmatized side.

  10. Well explained Ashley.

    The stigma of BPD is really sad.

    In my view The blame goes to both therapists and to the people at large.

    I understand that many times therapist comes to the conclusion that their treatment is not helping the patient.

    Forget about people in general, anyhow they make fun of everything.

    And therapists giving up?

    I understand that Dialectical Behaviour Therapy helps the patients.

    Always I gain something from your articles.

    Thank you Ashley.

  11. I wonder if it’s because it so chronic? The reason I say that is I’m a ‘general’ health trained nurse, and there are certain health conditions that are more, ‘popular’, for want of a better word. Patients feel more understood describing their cardiac problems, for example, than they do their neurological ones, because neurology is openly discussed as a ‘Cinderella’ service and is very unpopular. This means it’s understaffed and underfunded, and is considered like this mostly because it’s a condition that people struggle to deal with the most, and is not ‘pretty’ or ‘fashionable’ or giving quick results, or whatever. I’m probably not using the right words, if if it’s a *thing* with general health, it’s hardly surprising there’s a sub-group where it’s also a *thing*, with mental health. Hard for the sufferer though.

  12. As to why it’s so severely stigmatized, I think that (as with many mental health disorders) people are loathe to attribute some of the more unpleasant personality traits to things that are physiological or beyond one’s conscious control. Aside from angry outbursts and impulsive behavior, there’s a sense of desperation that seems to characterize people whom I’ve known who have a BPD diagnosis, and people get tired of this. I have a friend with BPD, and I am often frustrated that I don’t feel that anything I say or do stands a chance of actually helping her. The sense of “persistent emptiness” is particularly concerning, because it appears to come out off nowhere, and is often accompanied with suicidal ideations, or talk about past suicide attempts when she was in a similar frame of mind. I’m not a trained therapist, of course — just a friend. But because I do feel that my input is helpful to most of my friends, it is difficult that, no matter what my input, she returns to the same patterns. These include pursuing romantic relationships with men who really aren’t very good for her and sinking into a place of emptiness, involving parasuicidal expressions, when the man cheats on her, or the relationship doesn’t work out. One becomes depressed feeling how deep is her depression, and when the patterns are repeated over and over, seemingly without progress, it can be a drain on the energies of those who try to help her (especially when she doesn’t trust the doctors, therapists, etc.)

    This is all empirical observation. My daughter has an ex-boyfriend with BPD how was also abusive and does not let go. But again, this is only my personal observation. I have not personally known people with BPD to become happy or well-adjusted people.

    1. I think the attribution to conscious control plays a big role. Whether it’s expecting that someone with ADHD should just be more organized or someone on the autism spectrum should just make more eye contact or someone with depression should just shower more or someone with BPD should just change their relationship patterns, it’s all attributing things to conscious control that are actually a lot more complex.

  13. So… I have BPD and I honestly think it’s so stigmatized because of the word ‘personality’. The majority of the time people think I have multiple personalities or schizo when I do tell them about my BPD.

    Great post though!! Extremely accurate info!

  14. Good post, Ashley. Interesting to note that BPD is often misdiagnosed as bipolar disorder. I’ve been diagnosed as bipolar, but I’ve been helped by DBT which, as you note, seems to be originally a therapy created for BPD. I’ve always wondered if I had this personality disorder because I’ve shown many of these symptoms. After several years of therapy, though, the core issue of abandonment seems to have been resolved.

    Still, I’m not a “people person” at all and my extreme introversion and sometimes-cynicism about human nature makes me think it could be pathological sometimes, though I hope not.

    BPD definitely has a huge stigma, like you said, which is unfortunate.

    1. DBT has a lot of great concepts that can be useful for anyone, particularly people with mood disorders. I think wise mind in particular is absolutely brilliant.

      1. Agreed. The Distress Tolerance skills helped me tremendously during a very hard time in my life. They were really simple and obvious, but stuff I usually don’t think about when feeling overwhelmed.

  15. Good post! I have been deeply hurt by people with BPD (1 stalked me, another basically goes on public sprees writing against my friend with DID and me) but BPD doesn’t make a person automatically abusive. I wish people would see that but they often don’t, just like the “narc abuse” community.

    Know wonderful people with BPD too. I think the stigma is the whole “personality disorder” label, it’s so pervasive even among mental health professionals who should know better.

    My blog has some really old posts ranting about that since a therapist treating complex trauma characterised abusive people to be “personality disordered”. I’ve avoidant PD and will always remember how my T said “I definitely think you meet criteria but that doesn’t mean your personality is disordered.” And of course, the risk for PDs goes up with childhood maltreatment.

    1. There’s the childhood mistreatment issue, and the component that’s inherited, yet people, including professionals, seems so quick to leap to the conclusion that people chose to have a “bad” personality that makes them abusive. People with PDs can be abusive, and so can people without. There’s no need for therapists to buy into the nonsense.

  16. Diagnostic criteria don’t capture the depths of individual experience for any diagnosis, nor do I think it would be appropriate for them to try to. Even if a given diagnostic label applies, we’re all unique individuals with unique experiences.

  17. I’ve come back to this post because I really appreciate it and I think that I may actually still meet the criteria (even more than five in the DSM) for BPD. It’s easier to say I grew out of it because I did the work it took. However, a recent abandonment wound has really brought up a lot for me. As you may have noticed recently. Anyway, thanks again for being so compassionate, when most people are not, or it seems they aren’t.

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