Borderline Personality Disorder (BPD): a severe mood disorder characterised by emotional instability, black and white thinking, issues with self-image, reckless and impulsive behaviour…
Borderline Personality Disorder - what's it all about?
'She's a borderline. They'll stalk you.' That's the start and finish of what most people know about borderline personality
Believe it or not, and despite the inevitable initial puzzlement with the name "Borderline", our understanding of this most common, debilitating and anguish-provoking of personality disorders is much improved.
You'll often find on the web, and in occasional magazine articles, the odd light-hearted as well as one or two more serious attempts to assign 'clinical' diagnoses of "Borderline Personality Disorder" to well-known figures, both historical and living. It's often speculated, for example, that Marilyn Monroe, or Vincent Van Gough, or Hitler, Princess Diana, or Amy Winehouse, or Sarah Palin, even Tinker Bell from Peter Pan, Darth Vader, Shakespeare's version of Cleopatra, and Jessica Rabbit(!) have displayed 'borderline-ish' behaviours. Some have even gone so far as to assign the diagnosis of BPD to nation states.
And, quite often, the first time people hear about BPD is when someone, a doctor or clinician, or a well-meaning friend, raises the possibility of someone they know being "a bit borderline". But what does that mean?
A term first coined — by Adolph Stern — in the 1930s, Borderline Personality Disorder really has come quite a long way from the 'Freudian' "border between neurosis and psychosis". Today, it has a very specific classification, where one has to meet a minimum of five and a maximum of all nine (that's a possible 256 different combinations of symptoms that could result in a diagnosis of BPD) of the DSM criteria, or meet the general critera (F60) in the ICD-10.
Despite this, however, it's still very much the case that what's written and talked about BPD strikes a highly blaming, unenlightened, 'Fatal Attraction'-style tone — see, if you must, Joe Navarro ("FBI Special Agent (Ret.)"), How to Spot a Borderline Personality.
Borderline patients have, in the past, and can still today, be seen by clinicians as troublesome and resource hungry, who "won't" as much as "can't" be helped. And, cruelly, many Borderline patients, especially those who present particularly impaired interpersonal skills, can often alienate the very people whose care and support they seek.
No diagnosis feels more personal than that of [borderline personality disorder] … the problem is not an illness, the problem is you.
The BPD population: the numbers
According to one author, BPD is pretty common:
- BPD sufferers make up 2% of the population
- They make up 15% of those who seek counselling or psychotherapy
- About one-third of all those who commit suicide are diagnosed with BPD
- Of all those with eating disorders, alcoholism and drug abuse, BPD is present in approximately 50%
- Among all hospitalised BPD sufferers, or BPD sufferers in therapy, 70% will have attempted suicide before seeking help, and on average three times in their life.
- About 10% of those actually kill themselves — whether they mean to succeed is, obviously, unknown.
What causes Borderline Personality Disorder?
Marsha Linehan's biosocial theory of BPD is discussed elsewhere on this site, but Baron-Cohen's recent and extremely controversial theory of "empathy deficit" suggests early negative experiences of abuse, neglect and emotional invalidation will have decreased the amount of activity in certain brain regions, such as the amygdala, the medial prefrontal cortex, the middle cingulate cortex, the inferior frontal gyrus and the superior temporal sulcus — known collectively as the "Empathy Circuit".
This decrease in neural activity, combined with early life invalidation, causing exposure to higher levels of the so-called "stress hormone", Cortisol, has the potential to make one susceptible to Borderline behaviours such as destructive impulsivity, anger, mood swings, black and white thinking, rage, feelings of emptiness, and the rest.
Much of this anger is turned inward and can, therefore, be extremely self-destructive.
Borderline Traits and Tendencies
Navigating a way through the DSM can be tricky — rather like selecting from a complex menu — and it may prove slightly easier if one sees BPD as comprising four core tendencies: a tendency to engage in rocky and unstable relationships; a tendency towards extreme recklessness and impulsivity; towards extremes of emotions; and to distorted thinking.Borderline Personality Disorder DSM-IV-TR
1. Rocky Relationships
Someone with BPD will be all too aware of their track record of broken relationships: patterns of fallings-out with colleagues at work, some of whom will have moved departments or changed jobs just to avoid being in the same office as them; once closely-tied family members with whom they no longer have any contact; a long list of disastrous intimate relationships, ended angrily; friendships cut off at a moment's notice; and a history of therapy cut short because their therapists or doctors, at first admired, are now hated, because of the way they would challenge them.
Each relationship will likely have started out with enthusiasm, warmth and excitement, and then gone horribly wrong. It will have become such a pattern that each future relationship seems to have "abandonment" — the source of greatest anxiety — written into its DNA.
For those living with BPD, there is no grey area in relationships. They will enter them with impulsivity and quickly attach to their new partner, clinging, acting needy, and wanting to be with them 24-7. They work hard to please — their 'insurance policy' is avoidance of abandonment.
The relationship blows up angrily and acrimoniously, confirming in the borderline sufferer their view that s/he is "faulty", and destined to be abandoned the moment their significant other discovers who they really are.
"So I'll push you away from me before you abandon me"
The 'typical' response is either to then throw themselves into another relationship as quickly as possible, to ease the pain, or to push new partners away, as s/he is reminded how painful it is to be continually hurt.
Either way, abandoment becomes a self-fulfilling prophecy.
2. Impulsivity and Recklessness
Those living with BPD have a tendency to feel increasingly drawn to fill the deep well of emptiness they feel inside by satisfying immediate wants and desires, through, for example, out-of-control buying binges, taking out second mortgages and piling up debt to purchase extravagant, luxury holidays, expensive clothes, just to fill the wardrobes; gorging on supersize chocolate bars and cartons of ice cream; going into shops to steal relatively worthless items; binging, purging or both, trying to get more control in their lives or punish themselves by restricting what they eat, seeking out partner after partner, affair after affair, engaging in risky, unprotected sex; or driving too fast, sometimes with eyes closed, just for a few seconds, to feel something other than emptiness; or abusing inhibition-reducing substances such as alcohol, cannabis or cocaine, or so-called legal highs and herbal "essences", to numb out the acute emotional pain caused by their sensitivity to criticism or rejection.
"She's got a full bottle of pills hiding in her sock drawer, a packet of razor blades in the bathroom, and a suicide plan up her sleeve"
There is also the desire to inflict pain or harm on themselves, making sure they hide the scars from others, 'dealing' with, by distracting from, emotional pain, at least temporarily, to manage their self-disgust or self-loathing, by cutting, or burning, or banging their head against a wall, increasing the rush of endorphins, again to replace the numbness and emptiness, to somehow feel 'real', or to punish themselves, or to express the anger they feel for someone else, or to re-enact or continue a pattern of abuse they suffered in earlier life — see the self-harm and other case studies on this site.
Of course, the most serious, and complex of the impulsive and reckless behaviours that afflict people with Borderline Personality Disorder is suicidal acts; numerous attempts to try to escape what is, for many BPD sufferers, unbearable emotional pain, and the related feelings of helplessness and hopelessness that leads them to see their lives ending as their only hope — the view that no more life equals no more pain.
3. Chaotic and destructive emotions
Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.
With those afflicted with Borderline Personality Disorder, highs and lows come and go at random. People living with BPD tend to be consumed by their emotions, and are likely to experience negative emotions more often: more anxiety, more sadness, certainly more anger and jealousy, and less happiness or elation — a situation which worsens as the BPD develops.
Once these emotions have reached their most extreme level — or, as Stacy Pershall, author of the memoir, Loud in the House of Myself describes, once you're in "the midst of emotional overwhelm" — they take longer to calm. Furthermore, the events that trigger these powerful negative emotions are not necessarily that huge or life altering, and are often over-personalised.
It's likely that this emotional "dysregulation" is as a result of early life experience of invalidation — BPD normally manifests itself in early adulthood. Growing up, one may have been constantly told to "stop crying" as "crying is for sissies", or that you're so "lazy"/"clumsy"/"greedy"/"fussy" — the implication being that you have to put your own needs, feelings and pain on hold.
Pershall's memoir wonderfully describes this process of invalidation in early life leading to emotional dysregulation, which she gives the sobriquet "bad dog", in early adulthood:
"It spent a decade forming, gaining power. It made me fly into rages and cry hysterically at school. It ran through the threads of my nervous system. I was contaminated by it…This is how the Bad Dog came to live inside me"
4. Distorted thinking patterns
Those who suffer with BPD are likely to have developed extreme and distorted patterns of thinking.
It's considered an almost 'classic' feature of BPD that sufferers will see people and their behaviour in extremes — either idealising them, or demonising them — often flipping between the two. They seem to have a uniquely difficult time seeing the world as anything other than black or white, 'all good' or 'all bad':
Incorporating both positive and negative beliefs about a person, including oneself, is largely impossible. We see ourselves and others in an all-or-nothing way …
Of all the things that go on in my head, this has always been the hardest to explain to so-called normal people, and by far the most painful aspect of the illness
BPD sufferers are also likely to succumb to thoughts full of distrust and suspicion of others; the belief that most other people are dishonest and potentially harmful. A person with this pattern of thinking will interpret even the kindest gestures in a negative way.
Those with BPD may also show symptoms of dissociation, pseudo-hallucinations and a real sense of loss of or unstable sense of self. This feeling unreal, or of being detatched from self ("depersonalisation"), can give one a sense of one's personality as constantly changing, where you feel like you're no longer yourself, although it tends to stop short of feeling as though you're someone else. It also tends to be more frequent in those who are more intelligent, sensitive, affectionate, introverted and imaginative.
You might expect someone who presents with Borderline Personality Disorder, with all the characterlogical traits described (fear of abandonment, rocky relationships, emotionally triggered and consumed, prone to dissociating, and so on), to appear quite demoralised and helpless — perhaps overly so: actively passive. But, as often as not, patients will 'mask' the effects of BPD and appear quite the opposite: apparently competent. Both types of client present challenges to a therapist specialising in Borderline Personality Disorder.
Borderline Personality Disorder is manageable and there are many things people with the diagnosis can do to help themselves cope better and manage their condition. The majority of people with BPD feel better in the long term.