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Borderline Personality Disorder (BPD) Overview

Dancia is studying to become a Psychologist. She currently works as a health coach with a BA (Double Hons) in Psychology and Linguistics.

Shawn Coss' "inktober" art for BPD

Shawn Coss' "inktober" art for BPD

History

Borderline Personality Disorder (BPD) got its name because it was originally believed that the people who suffer from this mental illness were bordering "neurosis" and "psychosis."

Neurosis is considered as a mild mental health issue that is not caused by an organic disease. It includes symptoms of stress without descending to a loss of touch with reality. It causes a sense of distress and deficit in functioning. Some common illnesses include hypochondria, obsessive behaviour, and depression.

Psychosis is considered as a severe mental health disorder that alters the way the brain functions. It changes the way people perceive reality, causing people to see, hear, or believe things that are not real. It is a symptom rather than an illness. People with extreme depression, for instance, may experience psychosis. A well-known illness with extreme psychosis is Schizophrenia.

The first medically reported citing of BPD symptoms was 3000 years ago but it was not an official psychiatric diagnosis until 1980, appearing in the third version of the Diagnostic and Statistic Manual (DSM-III). The DSM is created by the American Psychiatric Association (APA). It is sometimes referred to as Emotionally Unstable Personality Disorder and Emotional Regulation Disorder for a couple of reasons. The diagnostic manual created by the World Health Organization (WHO), called the International Classification of Disease (ICD), refers to this illness as Emotionally Unstable Personality Disorder. Some people are campaigning to change the name to Emotional Regulation Disorder not only to decrease stigma, but also because it more accurately describes the condition.

Emotion Regulation Disorder Movement

Being diagnosed with a personality disorder can be distressing and further complicate the way that they view themselves. The idea of their personality being a disorder can create stigma against them and change the way they view themselves, leading to further difficulties in life. It invalidates their feelings of worth and makes them feel that this diagnosis is their fault. In addition, people with BPD typically have had a traumatic upbringing. The BPD appears to develop in result to the chronic trauma they endured.

By changing the name to Emotion Regulation Disorder, it can give more hope to those who are diagnosed with it. They would feel more able to change their habits and manage their thoughts and feelings. It can also reduce the stigma that people with this disorder are manipulative or attention-seeking as the name is more relatable. Everyone has emotions to regulate; some people just need more help.

By: Klar Em

By: Klar Em

Types of BPD

Depending on how the disorder manifests, two people with BPD can present differently. This is why it can be seen as a four-quadrant spectrum, resulting in four types of BPD. Please note that individuals are often a combination of these types, rather than fitting into one specific category.

  1. Discouraged
  2. Impulsive
  3. Petulant
  4. Self-Destructive

A Discouraged type is usually co-dependant and will do anything to make others happy, including sacrificing their own health and happiness. This is because they feel inadequate and would like to make up for their feelings of disappointment. Since they seek approval from others but are also afraid to let people down, they are sometimes conflicted with regard to taking on projects as well as supporting friends and family. Due to these mixed feelings, they tend to engage in self-harm behaviour and have suicidal tendencies.

An Impulsive type is energetic and charismatic. They are often bored, leading them to partake in impulsive behaviours such as extravagant spending. People in this category typically describe this as "act first, think later." This type will likely have a substance abuse problem and often self-harm. This can also be their way of avoiding abandonment.

A Petulant type is irritable and unpredictable. They will have extreme anger and resentment towards themselves and others. They appear to be easily disappointed by others and never obtain a sense of fulfillment. This type may partake in more extreme self harm behaviour to reflect their mental pain.

A Self-Destructive type is typically unaware of their behaviour, which is induced by self-loathing, a fear of abandonment, and lack of identity. By partaking in self-destructive behaviour, they make themselves "feel something," which validates their existence and pain.

Symptoms

There are four groups of symptoms for BPD:

  1. Emotional Instability/Affective Dysregulation
  2. Impulsive Behaviours
  3. Interpersonal Relationship Difficulties
  4. Cognitive Distortions/Perceptual Distortions

Emotional Instability or Affective Dysregulation is the intense experiencing of emotions. This is typically negative and leads to sorrow, shame, rage, panic, feelings of emptiness, and feelings of loneliness. They have intense mood swings that can vary in length. Sometimes the moods last for a few minutes and other times, it can last days. For instance, someone can feel suicidal and hopeless, then feel ecstatic a couple of hours later. They can have bouts of rage that are so extreme that they black out. Whereas the average person may have a 20% increase in anger about something, an individual with BPD may have an 80% increase in that same situation. The most important thing to do in these instances is get the person to calm down carefully or it may lead to impulsive or self harming behaviours due to their guilt and shame that follows the black-out rage.

Impulsive Behaviours are actions taken without thinking. They can be reckless and dangerous with immediate or long term effects. One of the common impulses with long term effects is money spending. This can be done by gambling, shopping, or large donations. They do this regardless of whether or not they need the money, causing them to be in debt. Self harming is a common impulse with immediate effects. This includes hitting themselves or throwing themselves at objects, cutting, or burning their flesh. Risky behaviour includes binging on drugs and alcohol, speeding when driving, having unprotected sex with strangers, and self-starvation.

Interpersonal Relationship Difficulty is having issues with people who are social associates, network connections, and affiliates. The difficulty is caused by feelings of loneliness and smothering. In one moment, an individual can feel alone or abandoned, and then suddenly feel overwhelmed and smothered by people.

People with BPD often struggle with abandonment issues, leading them to feel angry and anxious. This fear causes them to text or call abundantly and at inappropriate times. They can become controlling and clingy, especially in romantic or long-term relationships. As they learn how being controlling and clingy can be toxic, they may change the way that they cope with abandonment issues by physically clinging onto the person, making it difficult for the other person to move or leave. It might be seen as being playful or silly, but it is their way of managing their fears, whether they realize it or not.

Alternatively, they may withdraw from people with whom they are developing a close relationship. In contrast to fear of abandonment, an individual with BPD may feel that someone else is controlling or crowding them too much, again leading to feelings of anger and anxiety. This can also lead them to withdraw emotionally and physically. This type of behaviour is referred to as "Black-and-White Thinking."

Cognitive Distortions or Perceptual Distortions can drive people's moods drastically and intensely. These symptoms indicate that the person is becoming increasingly unwell and struggling to cope. They may require constant reassurance and validation from the people around them. For instance, they might constantly ask if they are a terrible person. The distortions can cause them to feel as if they do not exist or that they deserve to die. If they are happy, they may feel guilty or undeserving of happiness. Distressing beliefs may being to fester such as believing that their partner wants them dead and that they have been poisoned. They can have episodes of hallucinations and hearing voices, which can last a few moments or last for days.

Distortions of feeling unreal or that the world is unreal is called Dissociation. It is usually triggered by high levels of stress and cannot be controlled. It is an automatic self-defence mechanism that can been seen with others suffering with stress disorders such as Post-Traumatic Stress Disorder (PTSD), also known as Shell Shock Syndrome.

By: Agnes Cecile

By: Agnes Cecile

Developmental Factors

Like other mental disorders, there are various components to the development and progression of BPD. There are biophysical factors, such as genetics and brain development, as well as environmental factors, such as trauma and neglect.

Biophysical factors have been researched though twin studies and using magnetic resonance imaging (MRI). Although there is no specific gene(s) identified to affect the development of BPD, research suggests genetics does have an influence. Through examining identical twins, it was discovered that if one twin had BPD, there was a 2/3 chance that the other twin will develop BPD as well. When examining MRI results of people with BPD, it was noted that the brains had unusual levels of activity and certain parts of the brain were smaller than expected. These areas include the hippocampus (regulates self-control and behaviour), orbitofrontal cortex (responsible for decision making and planning), and amygdala (regulates emotions and consolidates memories). Neurotransmitters have been thought to play a role but there has not been enough concrete research to conclude this.

Environmental factors have been the most commonly researched and seen as the largest factor in developing BPD. These include neglect from a primary caregiver, chronic distress and fear from an early age, being a child victim to abuse over a sustained period of time, and growing up with a family member who has serious mental health problems.

Diagnosis and Comorbidities

Borderline Personality Disorder is defined by a pervasive and constant instability of interpersonal relationships, self-image, and emotions. It is marked by a level of impulsivity and begins in early adulthood. Since it is a personality disorder, it is present in a variety of contexts, as indicated with at least five of the following:

  • avoiding real or imagined abandonment through frantic behaviour, excluding suicidal or self-harming behaviour
  • a pattern of unstable yet intense interpersonal relationships, alternating their views between extreme idealization and devaluation
  • disturbance of identity: persistently unstable self of self or self-image (lack of identity)
  • impulsive in at least two ways that might be self damaging but does not include self harm or suicidal behaviour
  • recurrent suicidal behaviours, gestures, or threats, or self-mutilation
  • emotional instability (e.g., intense dysphoria, irritability, or anxiety, usually lasting a few hours and rarely a few days)
  • chronic feeling of emptiness
  • anger issues including inappropriate or intense anger, difficulty controlling anger, and continuous temperament
  • dissociative or paranoid symptoms due to stress

Some associated features include:

  • undermining themselves at the moment a goal is to be realized
  • some may have psychotic-like symptoms such as hallucinations during times of stress
  • may feel more secure with transitional objects (like pets or objects) than with people
  • premature death may occur, especially if co-occurring with depressive disorders or substance abuse disorders
  • may have physical handicaps due to self-inflicted mutilation and suicide attempts
  • recurrent job loss, interrupted education, and divorce are common
  • traumatic childhood history

Co-occurring disorders include depressive and bipolar disorders, substance abuse, eating disorders (particularly Bulimia Nervosa), stress disorders, and attention-deficit/hyperactivity disorder. People with BPD also often have other personality disorders.

Rorschach Brain

Rorschach Brain

Therapeutic Treatments

Psychotherapy allows people to find new coping mechanisms and new ways to approach a situation. It requires trust between the client and the person administering the treatment. For people with BPD, psychotherapy typically lasts less than three months. However, treatment is unfortunately lacking worldwide due to lack of specialization, lack of funding, and lack of resources. They can expect to wait two years for specialty psychotherapy treatment which includes Dialectical Behavioural Therapy (DBT), Mentalisation-Based Therapy (MBT), Therapeutic Communities (TC), Art Therapy, Cognitive Analytical Therapy (CAT), and Humanistic Therapies.

Admitting an individual into inpatient has shown to worsen symptoms or fail to improve their life so a Community Mental Health Team (CMHT) typically carries out the treatment in the UK. A team may consist of a psychiatrist, psychologist, social worker, community psychiatric nurse, occupational therapist, and pharmacist. A Care Program Approach (CPA) is then implemented in four steps. The first step is to assess the individual's health and needs. Then a care plan is designed around that assessment. A Care Coordinator (typically an Occupational Therapist, Nurse, or Social Worker) would then be assigned to become the main person delivering the treatment. Finally, reviews would be conducted on regular basis to ensure progress and to adjust the treatment as required.

Dialectical Behavioural Therapy (DBT) has been the most successful form of therapy amongst those with BPD. It has been seen to reduce some behaviours such as self-harm, impulsivity, and suicidal tendencies while improving traits such as distress tolerance, interpersonal relationships, and emotional stability. The creator of DBT, Marsha Linehan, is a world renowned psychologist who also suffers from BPD. This method aims to validate emotions and train dialectical thinking. Validation includes acknowledging emotions and accepting them, something that may not have been done in their childhood years. Dialectical thinking is to reduce the black and white thinking. It is broken down into four modules: mindfulness; emotional regulation; interpersonal relationships/effectiveness; and distress tolerance.

Mentalisation-Based Therapy (MBT) is a long-term treatment focusing on teaching individuals to think about thinking as people with BPD have a low capability to mentalise. This can be seen though their impulsive nature. This form of therapy helps people become more aware of their own thoughts, desires, and needs. It will also help them learn the impact of their actions with regard to other people. However, many believe this therapy is invalidating and struggle to come to peace with the knowledge of how their actions impact others. Since these feelings increase the risk of self-harm and suicidal tendencies, it is typically administered in hospitals and lasts 18 months.

Therapeutic Communities (TC) are structured environments where multiple with psychological needs come together to take part in therapy and interact with each other. Most are residential, expecting people to stay up to four days a week. They are operated on a democratic basis so it can be problematic if an individual is not accepted into the TC. It can cause them to feel invalidated and potentially increase the risk of self-harm. If they are accepted into the group, they are expected to help with chores in addition to the meetings and recreational activities.

Art Therapy is also known as Creative Therapy. It can be provided on an individual basis or in a group setting. This type of therapy includes visual arts, music, theatre, and dance. They are run by therapists who are specialized in the Arts. The goal is to help people express their thoughts and emotions in ways other than speech or writing as some people may find this difficult.

Cognitive Analytical Therapy (CAT) is a method of discussing previous events and experiences to develop an understanding of their current affects and behaviour. This is typically implemented after a course of DBT or incorporated into other forms of therapy. It is usually embedded into other therapeutic processes as the sessions are brief and last 13-16 sessions. The first few sessions will be centred around developing a relationship between the client and the therapist. They would touch upon past experiences to create a foundation or guideline for treatment, but would not explore or resolve the trauma at this point. The events are later mapped out in later sessions in order to find the root of various issues and present problematic patters of which the client may not have been aware. Once the patterns are noted and understood, change can begin by tackling the root of the problem, thus promoting newer and better ways of thinking.

Humanistic therapies delve into self-perception and teaches people to learn their strengths. It helps people see themselves in a positive perspective, increasing confidence, mood, self-esteem, and self-awareness. There are four types of humanistic therapies: Gestalt Therapy; Transpersonal Psychology; Person-Centred Counselling; and Existential Therapy. Gestalt Therapy looks through thoughts, actions, experiences, and feelings to improve self-awareness. Activities such as role-playing are often included in this type of treatment. Transpersonal Psychology encourages the dive deep inside themselves to explore who they are as a person. It adopts practices such as meditation and visualization. Person-Centred Counselling encourages people to realize that they are able to change and grow. It is easy to fall into patterns and assume that how they act and think will never change, especially when they have had this pattern for a long period of time. Through seeing experiences, thoughts, and feelings from the individual's perspective, this form of therapy emphasizes their drives to form both positive and negative habits. Existential Therapy encourages self-awareness, focusing on the present and future rather than the past. This can maintain some difficulties if the past has not been properly processed, restraining them from fully moving forward into their present and future.

When someone is in crisis, different therapeutic methods are implemented. Several resources such as telephone numbers and other immediate resources. It is considered a crisis when the individual is at risk to themselves or others. The crisis resolution team are trained to manage immediate and severe mental health issues who are experiencing a psychiatric crisis such as suicide attempts. The problem appears when people on these crisis lines are not fully trained to support people with more complex issues, leading to further frustration and potential isolation.

By: Steven Herbers

By: Steven Herbers

Medication

Medication may be used to manage BPD symptoms but none have been licensed specifically for this disorder. Due to this, it is typically prescribed when they have a co-morbid mental health condition. Anti-psychotics and mood stabilizers may be used to alleviate mood swings, impulses, and psychotic symptoms. Four classes of medications can be prescribed to reduce certain BPD symptoms. The effectiveness varies person to person, leading psychiatrists to adopt a 'trial-and-error' method of finding the optimal combination for every individual.

Anti-psychotics help with mood regulation, general functioning, symptoms of paranoia, and decrease suicide attempts and self-harm. Some examples include Flupentixol, Trifluoperazine, Thiothixene, and Haloperidol. If symptoms are particularly severe, they may be placed on atypical anti-psychotics such as Clozapine, Risperidone, Lurasidone, Olanzapine, Quetiapine, and Aripiprazole.

Mood Stabilizers improve emotion related symptoms. This includes anger, anxiety, depression, irritability, impulsivity, and unstable moods in general. Some common examples are Topamax, Lamictal, Depakote, and Anti-epileptics.

Anti-anxiety Agents improve anxiety, depression, agitation, and irritability symptoms. They include Buspirone, Lorazepam, Ativan, Clonazepam, Diastat, Niravam, and Xanax.

Nutraceutical Agents can improve anger, depression, and general aggression. Some examples are Omega-3 fatty acids, Ubiquinone, Melatonin, Levocarnitine, and Tryptophan.

Alternative Treatments

Nutrition

Nutrition has great impact on a person's wellbeing, both physically and mentally. Some nutritional supplements have shown desirables results in people with BPD. Though it should not be used in replacement of medical advice and prescribed medication, it can slightly alleviate symptoms naturally. These work similarly to nutraceutical agents. Magnesium is a natural muscle relaxant as it calms down the nervous system by blocking certain neurotransmitters. This makes it beneficial to those with BPD, Anxiety, Depression, and people who suffer from migraines. Omega 3 Fatty Acids are important from brain functioning as they are essential components of cell membranes. Within eight weeks of taking Omega 3 supplements, BPD patients have shown significant reduction in depression and aggression. Deficiencies in Vitamin D, which is prevalent in most people, have been shown to increase levels of depression and impact general mental health. By stabilizing Vitamin D levels, the intensity of depressive episodes can be reduced. Vitamin C can reduce nervousness, anxiety, and restlessness. Supplements of 500mg can significantly reduce anxiety.

By: Daehyun Kim

By: Daehyun Kim

Myths

Although misunderstandings are bound to happen, many of the myths surrounding BPD cause plenty of harm. They result in people reluctant to seek treatment in fear of being labelled or developing feelings of shame. This can also worsen many of their negative symptoms if they do not know how to properly manage the disorder. It can also create a stigma within society, making it more difficult to navigate through life normally and in a healthy way. This can lead to frustration, and lead them to spiral into self harming behaviours. This is why it is important to recognize and be educated in the truth surrounding common myths.

Myth #1: People with BPD are a burden

Everyone has struggles in their lives and living with BPD is just one of the struggles for some people. It is important that they get the support and treatment they require so they can better manage their disorder. If someone with BPD is starting to affect your own mental health, sit them down and explain that you do not currently have the capacity to help them but that you still care about them. It can be good to help them find resources dedicated to mental health management.

#2: People with BPD are abusive/attention seeking/manipulative

As mentioned earlier, BPD is a Cluster B personality disorder. This cluster is the dramatic cluster, which might be why they appear attention seeking. Although people with BPD can be manipulative or abusive, that is generally not their intention. The emotional outbursts and impulsiveness cause them to act in unpleasant ways. Their fear of abandonment may also lead them to act desperate to keep people around. To mitigate these behaviours, talk to them to increase their self-awareness and help them look for resources so they can learn how to manage the symptoms.

#3: People with BPD do not complete suicide

Approximately 10% of those with BPD will commit suicide, which is 400 times more than the UK average.

#4: People with BPD do not help themselves

There are many barriers to receiving mental health care, especially for those with BPD because of its complexity and high mortality rate. Unfortunately, many mental health practitioners reject people with BPD due to fear that they will mess up success rates. It is a flawed and unjust system that furthers the stigma and harms people with this disorder.

By: Christopher Hoggins

By: Christopher Hoggins

Resources

7Cups

AbilitiCBT

Better Help

Big White Wall Canada

Kids Help Phone

LifeLine

Youth Space

Sources

N.A. (n.d.). Borderline Personality Disorder Awareness Course. Centre of Excellence. https://www.centreofexcellence.com/shop/borderline-personality-disorder-awareness-course/

Theida, Kate. (2012). Emotional Abuse and Your Partner With BPD. Psych Central. Retrieved from https://psychcentral.com/blog/wellness/2012/01/emotional-abuse-and-your-partner-with-bpd#1

Bornovalova, M. A., Hicks, B. M., Iacono, W. G., & McGue, M. (2013). Longitudinal-Twin Study of Borderline Personality Disorder Traits and Substance Use in Adolescence: Developmental Change, Reciprocal Effects, and Genetic and Environmental Influences. Personality Disorders: Theory, Research, and Treatment, 4(1), 23–32. https://doi.org/10.1037/a0027178

N.A. (2019). Causes - Borderline personality disorder. NHS. Retrieved by https://www.nhs.uk/mental-health/conditions/borderline-personality-disorder/causes/

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2021 Dancia Susilo

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